Insurance 101
A fixed dollar amount an insured must pay out of pocket before their insurance begins paying for services renderd
Deductible
This government plan is divided into two regions - East and West and provides coverage to active-duty military members, retirees, and their families
Tricare
These plans commonly have a 3 letter alpha prefix in their member ID
Blue Cross Blue Sheild plans.
This is the J-code for Tysabri
J2323
The name of the test environment for Salesforce
The Sandbox
The percentage of the costs of medical services paid by the patient - usually applicable after a deductible is satisfied.
Coinsurnace
At the age of 65, a patient is automatically enrolled in this plan.
Medicare Part A
A High Deductible Plan (HDHP) is typically paired with this type of account
This is the J-code for Aduhelm
J3590 (unclassified code - subject to change upon approval)
If the procurement method for a Tysabri case is listed as B&B and SPP, we will have this many PBRL lines for a case with one medical payer and one pharmacy payer
4
A list of prescription drugs covered by a prescription drug plan
Formulary
This program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.
SCHIP/CHIP
This is the phone number for the Blue's Line
800-676-2583
This is the diagnosis code for generalized multiple sclerosis
G35
If we are provided two medical insurance plans for a patient and there is no coordination of benefits on file, we must do this to this case.
MCM - Send it back to the Biogen CM as needing additional information.
A code commonly used for non-orally administered medication and chemotherapy drugs. Only applicable to major medical benefits
J code
This type of plan replaces original Medicare
Medicare Advantage/Medicare Replacement (Medicare Part C)
These two types of plans do not offer out-of-network benefits
HMO and EPO
These four Biogen products are typically only covered via pharmacy benefits
Avonex, Plegridy, Tecfidera, Vumerity
Before you can generate the SOB, you must do this to your case
Disposition
A code used to identify medical diagnoses - used by insurance companies to identify why services were provided.
ICD-10/Diagnosis Code
This payer is the PBM for Tricare
Express Scripts
This payer is notorious for advising that they don't allow their calls to be recorded.
FL Blue/BCBS of FL
A list of pharmacies that are authorized to dispense Tysabri
Touch Pharmacies
These two billing entities can be designated in Salesforce when the site of care's NPI/Tax ID is used when verifying benefits
Account/Admin