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ULYSSES & CMT
HIPPA
FACETS & PEGA
Medical Insurance Terminology
Mandates and Federal Healthcare Reform
100
This is To Acknowledge, Gain Control, & Transition to Probing
What is Chill?
100
For members inquires these must be verified.
What is Caller's name and Members Name, Subscriber Number, Members full mailing address, Members Zip Code?
100
This Tab auto-populates with member and/or provider as well as group demographics once the required data is entered in the Customer Section.
What is Start a new call tab?
100
Individual must pay this before carefirst covers the cost of healthcare expenses
What is Deductible?
100
This is an official order or commission to do something in which an individual, group or organization mus comply.
What is a Mandate?
200
"So you called in to verify you claim on November 1st 2014 for the amount of $145 is that correct?" This statement is apart of the ______ part of The Call Strategy
What is Identify?
200
You accept these If the caller cannot provide all items for verification
What is Member Telephone Number, Members Date of Birth, Members Social Sercurity Number?
200
This screen appears when F6 is selected.
What is the Benefit Summary Screen?
200
This information identifies an individual regarding thier past, present, or future physical or mental health status, provisions of health care or paymenta for health care.
What is PHI?
200
These benefits are benefits that insurers are required by law to provide to cover the treatment of specfic health conditions certain types of healthcar providers and some categpries of dependants, such as children placed for adoption.
What is Mandated Benefits?
300
Provide Solution with options, Gain Acceptance, Recap & Provide next steps, and Ask, "Is there anything else?"
What is Satisfy?
300
These verification forms are needed if the caller is not the member and requesting detailed information on someone other than him/herself
What is an Authorization Form, Personal Representative Form, Other legal form(power of attorner, letter of adminstrativem guardianship, papers, etc.), or a Business Associate Agreement?
300
These fields at the bottom of the End Call/Routing dialog box must be completed to perform a closed first contact inquiry.
What is Subject, Category, Status, Proof of Closure, reason, Product Category, Satisfication Unit, Save changes, and end call/routing?
300
This is the Special Ranking for health insurance plans
What is Metal Level?
300
I stipulate that the annual or lifetime dollar limits must be the same or higher than the limits for regular medical beneifts if a health plan covers my type of services.
What is Mental Health Benefits?
400
"Yes you have resolved my issue and no there is nothing else." The subject & category for this task line is _____
What is M 1st Call Resolution-Inbound & Y-Issue Resolved/M-Anything Else?
400
This form is used to make a request to amend or revise thier PHI maintined by the insurer or its business associate.
What is an Amendment to PHI Request from?
400
This tab houses information about the applicant, such as name, social sercurity number, date of birth, address, height, city, state, and zip code in Pega.
What is the Application Tab?
400
This is the dollar amount of claims filed for eligible expenses at which point the member pain 100 percent of their out-of-pocket and the insurance begins to pay at 100 percent.
What is Stop Loss?
400
This helps consumers by reducing their monthly premuim to a more afforable rate and are calculated as a premuim cap based on income level.
What is the Advance Premuim Tax Credit?
500
When a call back is promised in 2 weeks you choose this in the drop down menu
What is Call Back 8-30?
500
This is the year the Federal government signed The Health Insurance Portability and Accountability Act.
What is 1996?
500
The symbol is required in a serch field when searching by namein Pega if you have incomplete information.
What is %?
500
This is an agreement between two or more health plans that permits a member of one plan to recevie treatment from another plan.
What is Reciprocity?
500
This is the exchange enrollment flow for applying for a subsidy.
What is Application Eligibility Determination, Subsidy Eligibility, Plan Selection, Notify Carriers, Intial Premuim Payment, and Confirmed Coverage?