Aetna & Cigna
BCBS/Carefirst
UHC
Medicaid
Medicare
Insurance Verification
Miscellaneous
100
Aetna HMO QPOS
Identifiers: "Choice POS II" top right
100
Carefirst BlueChoice
Identifiers: CareFirst BlueChoice logo top left AND local plan # 190/690
100
United Healthcare Select HMO
Identifiers: Individual Exchange - The exchange plans go under the UHC-HMO selection. Ignore the Optimum Choice identifier on the card.
100
Maryland Medicaid
100
Medicare Railroad
Identifiers: "Railroad Retirement Board" banner along the bottom
100
Which two options do we document in this field?
Verified or Deferred
Only use deferred if you’ve exhausted your efforts to verify the insurance and are still receiving an orange response.
100
When should you reference the Master Matrix AND where is it located?
The Master Matrix informs users of an insurance’s contracted status.
It’s located on the Managed Care Corner via the FH Intranet.
200
Cigna Healthcare PPO
Identifiers: PCP not on the card, No Referral Required top right
200
Carefirst/Blue Cross Blue Shield member ID numbers always begin with what?
Letter Prefix
Leaving out the letter prefix for a Carefirst/Blue Cross Blue Shield card can result in a denied claim.
200
United Community Plan
NON-CONTRACTED - Direct to an in-network provider
200
True or False: Staff must re-verify Medicaid payers on the DOS.
TRUE
Even if verified the day before the appointment, eligibility must be verified again on the date of service since it could terminate overnight.
200
What are the identifiers for a Medicare Advantage (aka Part C or Replacement) insurance?
-Medicare Rx logo
-'Medicare' and/or 'Advantage' on the card
200
True or False: Staff do not need to review the Eligibility Status field during check-in if the insurance was verified during scheduling or a chart check.
FALSE
It’s the front desk’s responsibility to ensure there is a response in the eligibility status field and the last eligibility date is within the correct timeframe:
-Medicare – Within the last month.
-Commercial Insurances – Within the last 14 days.
-Medicaid – Status date must be the same as the date of service.
-Deferred status - Always attempt to re-verify at the TOS.
-Start of a new month/year
200
To add a WC or auto insurance to the patient's chart, what must the patient supply?
The claim number. Without the claim number, staff will override and keep the account as Self-Pay.
300
Aetna Better Health of MD
NON-CONTRACTED - Direct to an in-network provider
300
BCBS NCAS BC
Identifiers: 'A' member ID prefix, 'W' group number prefix, union top right
300
United Health Shared Services/United Hlthcare Integrated Srv or GEHA
Identifiers: GEHA logo top left; Back of the card gives directions for different claims addresses based on if the patient also has Medicare primary.
300
True or False: Patients with a non-contracted Medicaid can opt to be self-pay to receive services at our facilities.
FALSE
300
True or False: When a patient has a Medicare Advantage insurance, you must delete their Medicare AB from their chart.
TRUE
Medicare Advantage insurances replace traditional Medicare AB. Staff must remove Medicare AB from the chart for correct billing.
300
Beyond telling us the insurance is eligible, what else can the insurance payer response let staff know?
-Co-pay amounts
-PCP selection (HMO & MCO insurances)
-Out-of-network benefits (non-contracted insurances)
-Plan effective/termination dates
300
For patients with Medicare:
When completing the MSP questionnaire, you can demo recall the responses within a certain timeframe. What is the timeframe?
Within the last 90 days
If the last MSP responses are older than 91 days, you must interview the patient for updated responses.
400
Cigna Healthcare
Identifiers: PCP indicated on the card
Card indicates POS, so the patient can use either HMO or PPO benefits.
400
CareFirst Commun Hlth Plan MD
400
UHC Dual MC Advantage
NON-CONTRACTED - Direct to an in-network provider
400
True or False: The patient is always their own guarantor for Medicaid payers, even if they are a minor.
FALSE
Patients are always their own subscriber when they have Medicaid.
Ex: A 5 year old patient will be their own subscriber for Priority Partners, but their legal guardian will be the guarantor.
400
When entering a Medicare Advantage insurance, what should you search in Expanse?
400
How should staff proceed when they receive this response?
Staff must review the submitted information for accuracy and question the patient about their insurance status.
-If the patient indicates they have other insurance, update and verify eligibility.
-If they do not indicate other insurance, proceed as self-pay.
400
For patients with financial assistance:
Where in the patient's chart do you check to review if their application is still valid?
500
Meritain Health
Identifiers: Meritain logo top left
500
BC Blue Cross Bluecard
Identifiers: Anthem, non-local plan # (131)
500
MC United Medicare PPO
Identifiers: AARP Medicare Advantage is part of the UHC network.
There is an AARP selection in Expanse, however, it is reserved for the supplemental plan.
500
What does this payer response indicate?
General Benefits indicate NON-COVERED for medical care services. Staff should interpret this as the patient having an MCO instead of straight Medicaid.
Also, review the orange text. This tells us which MCO covers the patient. If this text not present, staff must review the Full Response for this information.
500
Medicare Part A ONLY - Not to be billed for outpatient/ambulatory services
DO NOT enter into Expanse. Ask the patient if they have other medical coverage.
500
How do you proceed if you receive this response?
The patient has a Medicare Advantage – Staff must review the FULL RESPONSE to determine the advantage plan.
Staff must REMOVE Medicare AB, obtain the advantage plan, and enter into Expanse.
500
