Policy Terminology
How long does it take ACH to clear?
3-5 business day
What is medical repricing?
Medical Repricing is a process used by the insurance companies to negotiate and determine the appropriate reimbursement for the medical services
When members go to the doctor, what do members automatically receive if they stay within network?
Medical Repricing
The member’s mom called in and stated that her son is currently incarnated, and policy is active, what would you do?
Advise the member to have either the member contact us or send in proof of incarceration.
What are two ways you can update members payment?
Send an email or use drop down to process payment now
A member calls in requesting that their policy includes substance abuse, what two STM plans would you enroll member into?
Nexus and Summit
How does the deductible and the coinsurance work within a STM?
The deductible comes in to play for specific medical services being rendered and once the deductible is satisfied then the co-insurance kicks in to help the member with remaining balances. For example, on a $10,000 medical bill. If the customer had a $5,000 deductible and 80/20 coinsurance then they would first have to meet the deductible and then the insurance would cover 80% of the remaining balance.
What different platform you can use to locate a PAP form for member medication?
NeedyMeds and LillyCares
Explain the 2 ways he limited benefit works.
The network will reduce the cost of the doctor visit then the cash benefits will pay towards the service.
A member calls in stating they need an authorization for surgery, how would you proceed?
Advise member to call the eligibility department to get authorization code. Tell them where to get the information needed for contacting the correct department.
When creating TLD for members, what information should be completed?
Members contact information, dependents and policy
A member is over the age of 65 and wants to go the private health insurance route, what plan would you enroll member into?
Health Choice Silver
What is the timeframe for open enrollment?
November 1-December 15th although some states typically extend their open enrollment period to January 31st.
What specific information do you need to nominate a provider?
Providers contact information and NPI
A member called in with MEC policy and stated that she went to the pharmacy for a covid shot and didn’t receive coverage, what would you advise member?
For the member to get the coverage for the COVID shot it would have to be administered at the primary care provider.
Member calling in to cancel stating they receive a job offer and will be getting employer coverage through her employer, how would you proceed?
Educate the member of probationary period with their new insurance plan which is typically 60-90 days. Make sure that they do not cancel and leave themselves uninsured for that period of time. Set cancellation date for future date when their new policy begins
How do you send members an SMS through TLD?
Toggle the SMS icon on the bottom right of the screen
A member is currently 3 months, and she needs coverage for prenatal visit and the labor and delivery, what private plan would you provide the member with?
BWA 3
Explain pre-existing conditions.
Pre-existing is a medical illness or injury that members have before they start new health plan
What does it mean when the member is within their 5 day-billing cycle?
It means that the member is currently within a period of time where they must make the payment for the next billing cycle. Representative needs to notify the member that the hold will be removed, they will be billed again and that they can follow up within their next billing cycle if they want to submit a change request.
What is the maximum benefit for BestChoice Rx Level 1?
No maximum benefit
Member calls and states that she wants to cancel this policy because she is not getting the coverage needed, member states that she have an upcoming surgery, the member is getting tubal ligation, what would you advise the member?
Advise member the coverage is not medical necessary so no insurance would provide coverage, advise member that if the procedure is deemed necessary then that when the insurance can move with coverage to provide PPO repricing if they are visiting an in network provider
What does the cancellation note format include?
reason for cancellation, the rebuttals used, the outcome which should include manager approval and next step
A diabetic member calls in with a Federal Advantage plan and wants to know if he can get assistance with getting some diabetic supplies, what would you advise the member?
Advise member they can use the NCE Gapafford Plus card to get savings off their supplies
When does the additional deductible apply with an STM plan?
It only applies towards urgent care for traditional STMs
Explain an EOB
An EOB is an explanation of benefits; members receive this document after the claims have been submitted detailing how their insurance plan paid out.
Mr. Smith calls in stating that he just had surgery done and he received a bill and its states no coverage was provided by insurance. Mr. smith currently has an active secure health STM policy, what would you do?
Get the provider information to see if the provider in the network also educate Mr. Smith on how policy works. Advise Mr. Smith that if he hasn’t met his deductible that may be the main reason why coverage wasn’t provided and have Mr. Smith send EOB to support email for review. Insure him that we will do our very best to make sure this issue gets resolved.
Member calls in and stated that the sales agent advised them their Monjuaro would be covered at 100% and they went to the Pharmacy and no coverage was provided, what would you advise the member?
Advise member to have their provider change their medication to Ozempic and then we’ll be able to send the PAP form to get the medication at low to no cost.
What would you do if a $600 premium Fusion member wants to cancel?
What is the waiting period for cancer on Altura plan?
12 months