Terms
The amount you pay to the employer group for the cost of medical insurance
What is a premium?
The amount a provider agrees to accept for a service, this is what the benefit is based on
What is the allowed amount?
Prescription benefits are listed in these to determine how much the member should pay
What are tiers?
This system is used to take calls and chats
What is Genesys?
Confidential and protected information regarding a member
What is PHI?
The amount you have to pay before the insurance will start to pay on claims
What is a deductible?
This sections gives you the overview of claims processing
What is the synopsis tab?
This is used to determine if a medication is covered
What is the formulary?
This is used to pull a member's policy and search benefits and domestic providers and pharmacy
What is ISET?
This information is ok to release without having to ask permission- examples include benefits or provider search
The percentage you are responsible after meeting a deductible
What is coinsurance?
This section tells you what codes were billed and what the place of service is
What is the service lines tab?
This is required to show medically necessary for the diagnosis it is treating
This system is used to pull international members, providers and claims info
What is the global hub
This information requires either a release of information alert on file or direct verbal permission is received on the the call
What is medical and sensitive information?
A flat dollar amount you pay for a service
What is a copay/copayment?
A reprocessing of a claim because additional information was received
What is an adjustment?
This process is used to have members try lower cost alternatives before jumping to the most expensive option
What is step therapy?
This system houses all of your job aids and SOPS
What is Knowledge central?
This is the age that starts requirements for only being able to release general information, medical and sensitive requires either direct verbal consent or written permission on file
What is 13?
The maximum amount you pay before insurance covers everything at 100%
What is the out of pocket max?
This is where we send claims to be processed when members or providers email invoices to us
What is the RMO?
This spreadsheet is used to determine if certain medications require the use of special pharmacies
What is the specialty medication list?
This system is used to search members and enter detailed documentation on member interactions
What is SIMS?
The member can place this on their account to restrict information being released about them and/or any dependents
What is a password?