General Insurance
The insurance company who holds the insurance plan. Examples: Medicare, Medicaid, Aetna, Horizon
What is a payor
A federally funded health insurance program available mainly to people over 65 and to people with certain disabilities
What is Medicare
What is the Claim Address/ Mail Claim to address
Why is the Out of Network process in place?
What is a Federal Mandate/law
What logic in Epic helps determine filing order?
What is FOAL/Filing Order Adjustment Logic
The specific insurance policies under the insurance carrier. Examples would be Health Maintenance Organizations(HMOs), Exclusive provider organizations(EPOs), Point of Service(POS), Preferred provider organizations (PPOs).
What is a plan
A state funded plan that helps pay medical costs for people with limited incomes and resources.
What is Medicaid
A plan where the patient can receive services in-network without a referral. The insurance card will typically state if referral is required and the patient is not required to choose a PCP.
What is a PPO plan
Per federal mandate, when must the Out on Network workflow begin?
When is at time of scheduling the appointment
What will display as able to select if FOAL indicates the filing order is incorrect?
What is the Use Default button
The website to open every day to support users on insurances.
What is the Cooper Insurance Website
A policy helps pay some of the healthcare costs that traditional Medicare does not cover and is billed secondary to Federal Medicare.
What is the Medicare Supplement plan
Specific plan type referred to as Managed Care. This type of plan restricts the patient to use certain doctors and hospitals. Referrals are required for specialty services.
What is an HMO Plan
When must the Out of Network process be completed?
When is for every single encounter/visit
What areas does FOAL look at within the registration to determine filing order?
What are:
Subscriber is covered through field
Covered through
Employee size
MSPQ for Medicare eligible patients
Insurance carriers that cover patients through a government funded organization.
What are Government Insurances
These plan provide patients with their original Medicare benefits, usually their prescription drug coverage, and have a fixed out of pocket maximum amount
What are the Medicare Advantage plans/ Medicare Replacement plans
Member must seek healthcare ‘exclusively’ from the Professionals contracted with their plan.
What is an EPO plan
What must be signed for an Out of Network coverage for every encounter?
What is the Out of Network Informed Consent
For Medicare Advantage plans, what is listed on the patient level versus the encounter level?
What are:
Reg level- Medicare Advantage plan and Medicare
Encounter level- Medicare Advantage plan
Insurance carriers that cover patients based on their employment or organization.
What are Commercial insurance plans
Walk us through the steps taken in Epic for patients with a Medicare Advantage Plan?
(Be sure to mention what coverages are listed on Patient and Encounter level)
What are:
1. Run eligibility for Federal Medicare
2. Add Medicare and the Medicare Advantage Plans to the registration (be sure to read RTE and ensure the patient has active coverage for the service they are receiving)
3. Add the MBI and Name per the patient's card to the Coverage info link of Medicare Advantage plan.
4. Include Federal Medicare on the Registration Level
5. Remove Federal Medicare from the Encounter Level
With this plan, patients select an in-network PCP. Patients may receive services outside the network. Patients are responsible for most of the cost unless a referral is made from their PCP to the out-of-network Professional.
What is a POS plan
What type of note and what smart should be used when calling a coverage to verify the patient's eligibility?
What is:
Note type- Insurance
Smart Text- CUH Insurance Verified by Phone Template
For Dual SNP plans, what is listed on the patient level versus the encounter level?
What are:
Reg level- Medicare Advantage plan, Medicaid Advantage plan, Medicare, and Medicaid
Encounter level- Medicare Advantage plan, Medicaid Advantage plan