Payment Levels
Three payment levels in a benefit quote
What is.. Deductible, Coinsurance and/or Copay Amounts, and Out-of-pocket Maximum
Benefits quoted for office visit
What is.. Office visit, radiology and lab and other professional (in office procedures)?
Dental, Vision, Prescriciption carriers are loaded where
What is.. Other carrier information?
Check here for program participation
What is.. Wellness Programs?
Two types of plans members benefits run on
What is.. Plan year and Calendar year?
Which levels do you quote when a provider network status is unknown?
What is..ask the member which levels they would like to be quoted then only provide the benefit level they ask for.
MRI applies to what benefit first
What is.. Complex radiology?
Use this to pull up the members accurate benefit booklet
What is.. Product ID?
CPAP preauthorization is determined on
What is.. Sleep Medicine Management Program Participation?
Should be used in every benefit call. CPP stands for
What is.. Catch, Probe, Paraphrase?
Only required to quote if asked
What is.. Amounts applied to deducitble and out of pocket maximum?
Benefits quoted for Chiropractic
What is.. Office visits, spinal manipulations and rehabilitation (if for other modalities)?
What should be used in conjunction with the benefit booklet
What is.. Internal Reference Notes?
Does not have the DX or CPT codes but needs to check for preauth
What is.. Offer to contact the provider to obtain the codes and then review PA requirements?
Benefits from a pending SPD
What is..Give the disclaimer that only a limited summary is available for the current year and quote payment levels from the SBC?
Requirement when quoting coinsurance for any in-network and out-of-network benefits
What is.. Of the allowed amount?
Benefits quoted for Surgical
What is.. Professional benefits, outpatient or inpatient hospital benefit, and professional services for anesthesia if applicable?
Benefit Exceptions
What is..Do not refer members back to the employer to request an exception to the benefit coverage.
If a member wishes to dispute a benefit or limitation in the benefits, educate the member about the Member Appeals process.
Two other factors we use for preauthorization besides codes
What is.. Service Type and Level of Care?
If coverage is inactive/termed what should happen
What is.. the caller should be advised of this and benefits should not be quoted?
Cost member will have if provider performs multiple services subject to a copay on a single DOS
What is.. The system will bundle the copays to the higher copay amount?
Benefits quoted for Maternity
What is.. Radiology/Laboratory, preventive (breast pump), facility, professional services and newborn care?
Resources used in conjunction with the group page
What is..Benefits tab SDS, Benefit Quoting tool in SDS, KMT Tool?
Three services that in Physical Medicine Program that require preauthorization
What is.. Physical Therapy, Occupational Therapy and Speecy Therapy?
Required to quote if the benefit is subject to it
What is.. Maximums/Limitations (Dollar, Visit or Age limit), Exclusions and Waiting Period?