Cost Share
Using ID #3 provided by your instructor, access the plan for Haven Manor Health Care Center, LLC and answer the following question: What is the member’s benefit for a sick visit with an out of network Family Practice physician? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc.
No Coverage
Using ID #2 provided by your instructor, access the plan for Trustforte Corporation and answer the following question: How many in-network Home Health Care visits are allowed per calendar year?
40
Name one of the three types of Institute of Quality (IOQ) facilities.
BARIATRIC, CARDIAC OR ORTHOPEDIC
The member is calling because his wife has just come home from the hospital and is bedridden. The doctor prescribed home health care and the member would like to know if the LPN will be able to help his wife with her wound care, helping her get a shower and preparing her lunch as he has to work and he has no one else to help. What would you advise?
Using ID #2 provided by your instructor, access the plan for Trustforte Corporation and answer the following question: What is the member’s in-network benefit for an office visit with a dermatologist? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc. You can use Ctrl + F to search the document
70% AFTER DEDUCTIBLE NO COPAY. $5000 DEDUCTIBLE. COINSURANCE IS $6,500 INCLUDES ALL DEDUCTIBLES AND ALL COPAYS, ONCE COINSURANCE LIMIT IS MET, ALL DEDUCTIBLES AND ALL COPAYS NO LONGER APPLY.
Using ID 999062533, under the Member Allentown533 file, answer the following question for Member: If the member has outpatient surgery at an in-network hospital with an in-network specialist, what is the member’s benefit for anesthesia charges? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc.
80% AFTER $200 DEDUCTIBLE. COINSURANCE $1,000 - INCLUDES DEDUCTIBLE.
Pregnant members do not have to pay any out of pocket costs for ultrasounds because they are covered under the global maternity fee.
FALSE
This is an administrative procedure for services not found on the participating provider precertification list, where a medical professional submits a treatment plan to the insurance carrier before treatment begins so the carrier can indicate the patient’s eligibility, costs and plan maximums.
PREDETERMINATION
Routine prenatal care includes all the following EXCEPT: (3 Points)
A. Fetal Heart Tones
B. Genetic Testing
C. Physical exams
D. Routine chemical urinalysis
B. Genetic Testing
Using ID #2 provided by your instructor, access the plan for Trustforte Corporation and answer the following question: What is the member’s in-network benefit for a routine vision exam? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc. You can use Ctrl + F to search the document.
100% NO DEDUCTIBLE AFTER COPAY 1 ROUTINE EXAM MAXIMUM PER 24 MONTHS. VISION COPAY $0
Using ID 999062533, under the Member Allentown533 file, answer the following question for Member: What is the member’s benefit for the hospital for an in-network, inpatient surgical procedure? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc.
80% AFTER $200 DEDUCTIBLE. COINSURANCE $1,000 - INCLUDES DEDUCTIBLE
Out of network providers don’t have contracts with Aetna therefore we can’t force them to accept our rates for services. They may bill the patient up to their full submitted amount.
TRUE
This is a community based store concept that focuses on helping customers get well and stay well and offers expanded healthcare services and well ness products for everyday care and chronic conditions
HEALTHHUBS
Using the screenshot, answer the following question: These services were authorized to take place:
a. Inpatient
b. Can’t be determined with the information given
c. Outpatient
d. Emergency Room
c. Outpatient
Using ID #1 provided by your instructor, access the plan for Lyon County School District and answer the following question: What is the member’s in-network benefit for an electric breast pump? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc. You can use Ctrl + F to search the document.
100% NO DEDUCTIBLE NO COPAY AND FOR ELECTRIC BREAST PUMP LIMITED TO 1 PER 36 MONTHS
Using ID #3 provided by your instructor, access the plan for Haven Manor Health Care Center, LLC and answer the following question: What is the member’s benefit for an emergency service at the emergency room? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc.
100% NO DEDUCTIBLE AFTER $750 COPAY FOR EMERGENCY USE OF EMERGENCY ROOM WAIVED IF CONFINED AND NOT COVERED: NON EMERGENCY USE OF EMERGENCY ROOM
Aetna standardly covers foot orthotics on all plans.
FALSE
When members choose a par hospital, many times non-par providers perform other services as part of the hospital service. In these instances, members don’t have a choice. When patients don’t have a choice, we cover the services at the higher benefit level for certain provider types. What is the acronym used to refer to these provider types?
HAIRPENS
Using the screenshot, answer the following question: This elective service was:
a. Approved
b. Denied
c. Can’t be determined with the information given
d. Pending
a. Approved
Using ID #1 provided by your instructor, access the plan for Lyon County School District and answer the following question: What is the member’s benefit for an In-Network Chiropractor? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc. You can use Ctrl + F to search the document
100% NO DEDUCTIBLE AFTER $20 COPAY 12 VISITS MAXIMUM PER YEAR
Using ID #3 provided by your instructor, access the plan for Haven Manor Health Care Center, LLC and answer the following question: What is the member’s benefit for an in-network sick visit with a Family Practice physician? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc. (5 Points)
100% NO DEDUCTIBLE AFTER $30 COPAY FOR INTERNAL MEDICINE, PEDIATRICS, FAMILY PRACTICE, GENERAL MEDICINE
Elective Out of the Country Services can never be covered under a member’s plan
False
The member calls and provides procedure code 28293 and diagnosis code M20.23. They would like to know if the services will be allowed or denied. What would you advise?
Denied
All the following are types of Infertility coverage the member may have EXCEPT: (3 Points)
A. Comprehensive
B. Basic
C. Maximum
D. Advanced Reproductive Technology (ART)
C. Maximum
Using ID #1 provided by your instructor, access the plan for Lyon County School District and answer the following question: What is the member’s benefit for an in-network routine mammogram? Please provide the full benefit that should be quoted to the member including any applicable deductible, coinsurance, copay, OOP limits, etc. You can use Ctrl + F to search the document.
100% NO DEDUCTIBLE NO COPAY FOR ROUTINE MAMMOGRAM NO AGE OR FREQUENCY LIMITS