Medical Basic Benefits
What is the difference between preventive and diagnostic services?
preventive services are the ones member uses to help stay healthy, prevents illness or detect illness early. Diagnostic services are the ones member uses to identify the cause of symptoms or threat the illness.
In what tab of debut do you find the copay and vendor for transportation?
transportation tab
What is the difference between authorization and referral?
authorization is for medical procedures or equipment and a referral is for a medical visit.
What are additional benefits not covered by original medicare, but covered by medicare advantage part c?
Vision, dental & hearing.
True or False:
Do you make the eligibility survey with the member to get the spending card benefit?
True
Ancillary providers ( PARE) are Pathologists, Anesthesiologist, ________, emergency room physicians.
Radiologists.
In what tab of debut do you find the benefit for over the counter allowance?
OTC tab
What are the authorization status?
Approved, denied, partially denied, pending and voided
What is the humana wellness and incentive program called?
Go365
True or False:
All plans have the otc benefit.
False
What is deductible, copay and coinsurance?
Deductible: amount member must pay out of their own pocket before humana will pay any expenses.
Copay: fixed amount defines in the insurance plan and paid by a member each time specific medical services are provided
Coinsurance: Money or percentage that an individual is required to pay for services after a deductible has been paid.
In what tab of debut do you find the copay for and MRI?
Radiology tab
Provide word choice when the status of an authorization is denied with not medically necessary code.
positive word choice
Can you mention a hearing and vision vendor?
eyemed & truhearing
True or False:
You handle go365 related calls.
false
What is the VOB cycle ( perfect call cycle)?
Quote the benefit -- Locate the provider --- locate if an authorization or referral is needed.
In what tab of debut do you find the copay for an injection medication part b?
pharmacy tab
Practiceeee:
Locate in referral guidance tool a stat that requires a referral from pcp.
varios states
What is the name and what covers humana fitness program?
silversneakers includes membership to thousands of network fitness locations nation wide.
True or False:
We use C/I misrouted call/ transfer to correct skill, when we transfer the call to other department or tier level?
FAAAALLLSEEEEEEE
Describe the post acute care services: inpatient rehab facility, skilled nursing facility, home health care and hospice.
inpatient rehab facility: member stays to get therapy at least 3 hours per day
skilled nursing facility: member need 24h help cant do therapy 3 hours a day.
home health care: medical care delivered in patient home, does not required 24h care
hospice: care and support people in the final phase of terminal illness.
Where can we find additional help for members in their communities?
Humana community navigator
practiceee
How would you quote Nuclear medicine: quote the benefit, locate if authorization is needed and locate a provider.
practiceee
Explain the 3 spending card allowances.
Humana helthy option: this allowance can be use to purchase food, pay bills, routine transportation, pet care and more.
Humana flex allowance: is used to pay dental, vision and hearing services.
Over the counter allowance: is used to buy over the counter item, this are medical item that are sale with out a medical prescription.
True or False:
Being below the poverty line income makes an American qualifies to Medicare.
Falseeeeee