Grievances
What is 30 calendar days?
Enrollment periods
What is Initial coverage election period, AEP and OEP
Member Cost Share
What is Copay, Coinsurance, Deductible
what does LEP stand for and the meaning
What is Late Enrollment Penalty is permanent and applies for all Medicare plans. It is a penalty on individuals who do not maintain creditable coverage for a period of 63 days or longer following their initial enrollment period for the Medicare prescription drug benefit or a subsequent gap of 63 days in between one coverage to another.
Authorization vs Referral
what is
Authorization — An agreement between Anthem and a provider that a specific service for a specific member is medically necessary. Authorizations have a beginning and an end date.
Referral — A referral is when a member’s PCP feels their medical condition requires them to see a specialist. The PCP will give the name of a specialist/facility they recommend the member see or go to, and will advise the specialist that they are referring the member to them. A referral is not an authorization issued by Anthem. Click here for additional PCP and specialist referral talking points.
Type of authorization form for a grievance
what is AOR- Appointment of Representative
the teams that handle enrollment and plan changes
what is HPA and Loyalty
Member Submitted Claims turn-around time
what is 60 Calendar Days
Creditable Coverages
Pending Authorization meaning
what is an authorization that has been entered into Compass and the pend code has been added to the authorization to prevent claims payment for a specific action. The action needed could be additional clinical, case rate negotiation, etc.
When to file a grievance
What is any time a member expression of dissatisfaction with any aspect
OSB enrollment period
What is during AEP, or within the first 90 days of their plan effective date.
when a member disagrees with cost share
what is appeal rights
Attestation timeframe with insurance
what is If attestation not received within 30 days of the date of the letter, the LEP will be assessed but the health plan has 60 additional days to remove the LEP
Timeframe for standard authorization
what is
Where to find a resolution
what is Dochub/Macess or VAM
OEV Letter
What is Outbound Enrollment Verification members may have an additional period to cancel their plan after the effective date
Where to find a DOFR
What is
Compass > Composite screen > Member Info tab > PCP Section > Double-click current PCP > scroll down to “Delegated Risk Information” section > Press “View DOFR” button
where are LEP letters housed
What is Medisys
where do to check to see if a CPT code needs authorization
What is Pluto
3 types of grievances that can be sent to MCAG
What is Access to Care, Quality of care and Broker misrepresentation?
SEP Qualifications
what is Dual eligible, address change, employer plan change, disenroll from Part D to enroll in Creditable Coverage, change in LIS level, chronic condition
How to find the MOOP in compass
what is
C2C
What is the dept to appeal an LEP after the 90 days
what does Carelon PAS handle
what is Home Health, Post-Acute Care, SNF, LTAC, Inpatient Management and DME