Eligibility, Enrollment, and ID Card
How long should be the timeframe in ordering the member's physical ID Card after it's issuance?
14 Calendar days or 7-10 Business Days
The task primarily used to check member's benefits
Benefits and Cost task
An individual or entity that delivers medical care, and there are several types of providers that can serve as primary care physicians/providers (PCPs), including family practice, general practice, internal medicine, pediatricians, nurse practitioners, and physician assistants.
Provider
It refers to a health care plan's legal right to recover sums paid for a member's health care from a legally liable party, the liable party's insurer, or a workers' compensation insurer or program.
Subrogation
This stool is use to manage and track claims, as well as store and retrieve documents, including claim images and member-submitted claims, allowing users to effectively manage the claims process.
WellPoint Content Framework (WCF)
A system used for processing and managing enrollment applications, including individual and small group applications, both on and off exchange, as well as Affordable Care Act (ACA) applications. It is accessible through a single sign-on link and provides various components such as member enrollment, group enrollment, paper enrollment, and admin functionalities.
Integrated Enterprise Enrollment Engine (IE3)
This refer to services provided by healthcare professionals, such as doctors and nurses
Professional Services
An application that uses data supplied by the BCBSA, which allows members to search for providers, including doctors and hospitals, in their network.
Find Care
It is the practice of ensuring that insurance claims are not paid multiple times when an enrollee is covered by more than one health plan at the same time.
Coordination of Benefits (COB)
L0112: Custom-fitted knee orthosis, rigid, without a knee joint is example of what kind of code?
HCPCS or Healthcare Common Procedure Coding System
A code assigned to members to ensure the correct benefits are applied based on their eligibility status, such as Medicare eligibility or non-Medicare eligibility, and it can also refer to codes used to identify specific types of contracts, such as durational or non-durational contracts with providers, or to represent different product types like medical, dental, or vision, and subscriber relationships.
Contract Code
An artificial intelligence (AI) tool that assists with quoting benefits and coverage within the Benefits and Cost Task in Solution Central.
Personalized Benefit Quote (PBQ)
This occurs when a provider bills a patient for all charges not paid by the insurance plan, even if those charges are above the plan's allowed amount or are considered not medically necessary.
Balance Billing
Special types of records that contain COB/MED primacy information, notes from E&B, and special processing instructions for claim examiners.
Limited Liability
The 5 W's of Claim Research.
This information asks why the services were being rendered or why the patient went in and visited the doctor.
Diagnosis
Jenny, an associate receives a call from one of our members, Harold. He would like to know if he has an ID Card for his plan. What detail we should check first to determine if we are going to order an ID Card to the member or not.
The medical management system (MMS) for utilization review of outpatient and inpatient cases. It is used by utilization management (UM) nurses to review requests for authorization of healthcare services and by case management nurses to document information in a member's case.
Anthem Care Management Platform (ACMP)
Whenever the main tool is not working, we use this tool in carrying out functions for updating PCP for member and checking Provider Network Status.
CA Mainframe
Veronica and Archie are unmarried and both have Anthem plans. They have a daughter named Betty who is part of both plans. Veronica and Archie has the same birthday but Archie is currently 27 tears old while Veronica is 28. Veronica's plan started January 1, 2020 while Archie's started his plan last February 1, 2019. What rule(s) is/(are) being followed for this scenario?
Children of Unmarried Parents, Birthday Rule, Longer/shorter rule
An AI-enabled chatbot designed to assist associates with claim processing and understanding denials, and to provide accurate and timely information about claims to members.
Agent Assist Claim Inquiry (AACI),
This serves as the reference number and starts with I-C followed by numbers
Interaction ID
This tool is used to streamline the process of searching and identifying Current Procedural Terminology (CPT) codes and their corresponding descriptions, including determining if a procedure code is preventive and locating benefits for travel immunizations.
Lookup Code tool in Solution Central
The source system being used in finding in-network providers.
SPS_Anthem
We utilize the Anthem Spending Accounts Tier 1/Tier 2 Call Chart for all Spending Account concerns, when talking to the member, we refer to them as what?
Spending Account Experts
This claim status states the claim might be paid or not, but member has a financial responsibility because they haven't met their deductible yet.
Deductible