Benefits Stuff
This is the document you can find in KIP by searching the member's PBP or plan code from MC400. It should be used to quote benefits because it is a complete, legal document.
What is EOC (Evidence of Coverage)?
A request for the Plan to cover a medication at a lower tier (Tiering Exception) is a kind of this.
What is CDAG (Coverage Determination)?
This is the specific code used to check coverage for a medication.
What is BNA205?
DAILY DOUBLE!!
This system can be used to look at premium invoices, HIPAA forms, enrollment applications, reimbursements on paper and more.
What is FileNet?
These are the TWO ways you can check coverage for a medication.
What are formulary (combined with LIS grid) AND ESD?
An example of this would be: A member disputes their copays and deductible amounts on the plan in general, stating the cannot afford care and feel that the plan is not a good value.
What is a complaint/grievance?
3-letter Category Code for finding providers.
What is PVA?
This system is an up-to-date database where you can find plan benefits info, tip sheets, mailings sent to the member, and more.
What is KIP?
The first level of the appeals process (completed with the Plan) for a denied ODAG.
What is reconsideration?
DAILY DOUBLE!!
This code is used to change a Medicare member's PCP.
What is PVB032?
This system is used for ordering bathroom safety devices, looking for travel benefit providers, performing a verbal plan change, and more.
What is Medicare Resource Guide SharePoint?
This type of care is different from home health or skilled nursing, and is not covered by Medicare nor UPMC for Life, because it is not primarily medical in nature.
What is custodial care?
The timeframe for a standard grievance to be processed.
What is 30 days?
These codes (3-letter Category Codes) are used when discussing Premium Billing.
What are IVB codes?
This is the first system to be used for Web Support Calls, to find the member's user ID and see other important info.
Policies can be accessed through MCN or upmchealthplan.com>I'm a Provider. If the policy begins with MP.PA it means this.
What is "prior authorization needed?"
The timeframe for a standard CDAG to be processed.
What is 72 hours?
This is the code for a UPMC for Life member address change.
What is END012?
(END015 for Dual SNP)
This is a read-only system for looking at Complaints/Grievances and Appeals.