Commercial Products
The first of these plans have no clinical services and no notification required, while the other of these plans have some clinical services included and some notification required. Both do not have a provider network, meaning member choose their own providers.
What are the Indemnity and Managed Indemnity plans?
Consumer Driven Health Plans include these types of accounts.
What are HRA/HSA/FSA?
These are some keywords we can use to locate office visit benefits.
What are office, primary, specialist, or physician?
*Use probing questions to identify if this is for a PCP or specialist visit.
The member's funding arrangement is found in this section of Spire.
What is the Policy Details section under 'funding arrangement'?
The process for quoting all benefit types can be found here.
These plans both require member notification and have out of network benefits, but the first one has a benefit differential. The second plan does not have a benefit differential.
What are the PP0 and PP1 plans?
If the provider asks about a Health Savings Account, more commonly referred to as a Health Savings Plan, I can check this section in Spire. I can also check for a Health Reimbursement Account or Flexible Spending Account in this same section.
What is the benefit details section of Spire?
*Spire will highlight HRA or HSA in yellow to the right of benefits, and/or advocate can search 'HRA, HSA, or FSA' in the benefits search bar.
Some benefits can be categorized as diagnostic or preventive, depending on the patient's situation. We call these services the Big 3.
What are Mammograms, Colonoscopies, and Bone Density Scans?
This is the benefit category for CT Scans, PET scans, MRI, MRA, and Nuclear Medicine.
What is Major Diagnostic Imaging?
This link is found on the Spire website to easily locate resources.
What is the Spire Toolkit?
Indemnity Plans, POS Plans, HMO Plans, and EPO Plans are all ___ types of plans, while PPO Plans are ___ types of plans.
What are Managed Care Plans and Non-Managed Care Plans?
If UHC is NOT the primary payer, we can check this section of Spire for COB Provision information.
What is the Benefit Details Section, by typing in COB into the benefits search bar?
This is the benefit category that includes services such as screenings, check-ups, and patient counseling, rendered to prevent illnesses, disease, or other health problems.
What are Preventive Care Services?
This is the most common radiological procedure utilized for imaging, and it is found in this benefit category.
What is Minor Lab, X-Ray, and Diagnostic?
The purpose of locating the COB index cards is this.
Pathway: Spire Toolkit> Benefits> Cob preservice> COB Field definitions> online index cards Then click Coordination of Benefits> COB Definitions (right side list)
What is the COB provision explanation?
Both of these plan types encourage a PCP but one is not required. For the first plan type, there are no OON benefits, while the second plan type pays OON benefits at a lower rate and requires notification for these OON treatments.
Hint: Plan 1 includes Product Indicators EP1, MH6, and HM8. Plan 2 includes Product Indicators PS1, HM7, HM9, and HMA.
What are Choice and Choice Plus plans?
After finding that a member has a COBRA plan in the policy details section, I can check this section for more information on it.
What is the Benefit Details Section, by typing COBRA into the benefit search bar?
We can ask the provider, "Are you checking the benefits for the physician fees or facility charges?", when quoting this benefit.
What is the Outpatient Surgery benefit.
If a member's benefits show Tier 1, INN, and OON options to quote from, we can check here for the provider's tier.
Where is the provider status?
This is where we should locate prior authorization requirements before checking anywhere else.