Part A and B
What Does Part A include?
What is hospital/In person Services
What does HMO Stand For?
What is Health Maintenance Organization
What is Tier 1?
What is genetic
What is the main system we use?
What is Compass
What is another name for Coverage Cap?
Donut hole
What Does Part B Include?
What is Medical/ Out patient Services
Has no out of Network Benefits EXCEPT if..
Doctor is out of state and can perform procedure
What are prescriptions subscribed for?
30 days
Used to search up provider/provider info, or member/member info
CPSUI ( contact reference shared user interface)
What do we handle?
Which of the following will Part B never pay for: Diagnostic Tests Inpatient mental health services Medications administered in a physicians office
Inpatient mental health services
If a member called and has an HMO plan will the member be able to set up appointment with out of network doctor? please state what would be the process
No, the member would have to go with an in network doctor unless its an emergency. Otherwise the member doctor would have to get a pre-auth from the provider stating they need the services done.
What computer system will you use to mainly view pharmacy?
ESI aka Express Scripts
We would use this system to see if their is a P.O.A on file
CIRS
If the member is deceased check ____ first to see if anything is updated
MARX
It is January and Helen is 66 years old and has part A. Her job was recently terminated and she decided to take the 18 months of COBRA her employer offered to her. What will happen when her COBRA ends and she decides to sign up for Medicare?
Because COBRA is not considered insurance based on current employment, Helen will have to wait until the General Enrollment period (January-March) to sign up for Part B and it will not begin until July. She will also be penalized for not have Part B. She can, however, sign up for Part D without penalty.
Does HMO have deductibles?
YES
Where providers can initiate Part D
PA hub
This system is used for reviewing auth requirements for CPT codes
PLUTO
What does a Member Need in order to qualify for Part C?
Part A & B
What is Managed Care?
A group of activities intended to reduce the cost of providing for profit health care while improving the quality of that care.
Preferred Pharmacy is the same thing as...
Receiving it in the mail
We use this system to view ID cards
Clarity
Anything more than 5 digits (under codes)
Modifiers