Terminology
This was designed to make it easier to compare plans, the federal government created four levels of coverage: platinum, gold, silver, and bronze. Platinum health plans have the highest premiums, but have the lowest costs each time you receive care. Bronze health plans have the lowest premiums, but have the highest costs each time you receive care. Gold and silver plans offer more of a balance.
What is Metallic Level
With this benefit a provider can hold the member responsible for the total cost and not just the eligible amount (contracted amount) for the maximum allowance.
What is Balanced Billing
This will cause you to fail quality assurance immediately.
Not HIPAA verifying or verifying inaccurately.
When on a call with a member requesting verification info you are not to request this.
What is Social Security number.
Translation services are available to assist our members who speak any language other than English. All Customer Service Team members for Independence Blue Cross (Independence) and AmeriHealth have access to_______________for translation services.
CyraCom
This means employers must offer health coverage to their employees beginning in 2014, or face a tax penalty. The penalty increases in successive years.
What is the Insurance Mandate for Employers
This represents all the benefit information captured during the call, and can be used as reference when relaying the benefit information to the caller
What is the Quote Benefits page in CSD
This statement should be made after the caller’s request or reason for the call has been stated and before a reply or answer to the requests are given to the caller. However, the CSR may express empathy.
What is assurance statement.
Form that provides legal authority to act on a member’s behalf in making decisions related to the member’s health care.
What is Personal Representative Form
A provider wants to know if a code is valid and billable. The provider states that he or she has had issues with the particular code in the past.
What is Medical Policy
This is any supplemental, additional secondary services rendered in a hospital, except for room and board charges and professional services; Ancillary Services include laboratory, radiology, physical therapy and respiratory therapy provided in conjunction with medical or hospital care.
What is Ancillary Services
PHO and Proactive HMO plans will have ________ provider system.
a Tier based
These are examples of what:
• “Thank you for calling Customer Service. This is <insert name>. May
I get a call back number?”
• “Thank you for calling Customer Service. This is <insert name>. May
I get your member ID?”
• “Thank you for calling Customer Service. This is <insert name>. It is my goal to resolve the reason for your call.”
• “Thank you for calling Customer Service. This is <insert name>. Who do I have the pleasure of speaking with?”
Incorrect, wrong, not accurate ways to greet the member.
These are example of:
• Name • Address (includes street address, city, county, ZIP code, and other geographic information) • Date of birth • Telephone number • Email address • Social Security number • Account number • Billing history and invoice information • Spending account information • Group/Client Name
(PHI) Protected health information
This is where you would go to email HIPPA authorization to release form.
Customer Resource Center
This is a cost containment program that recovers money for healthcare where primary responsibility does not exist because of another group health plan or contractual exclusions. Includes coordination of benefits, Workers' Compensation, subrogation and no-fault auto insurance.
What is Other Party Liability (OPL)
These are examples of what
• Preventive, wellness, and disease management services • Pediatric services, including dental and vision • Emergency care • Prescription drugs • Ambulatory services • Laboratory services • Hospitalization • Mental health, behavioral health, and substance abuse services • Maternity and newborn services • Rehabilitation and habilitation services
What are Essential Benefits
This is an example of what.
"Now that we have completed reviewing your claims and went over your benefits, is there anything else I can help you with today?"
What is recap
There is an authorization on file for Mary to speak on behalf of Jon. Mary called to get claim details about Jon but is told we cannot release the information. What is a reason that could be?
Confidential Communication
This enables IBC Personal Choice/PPO and Traditional members to receive inpatient and outpatient hospital care and physician services when traveling outside of the United States. The program includes medical assistance services and an expanded network of health care providers throughout the world.
What is The Blue Cross Blue Shield Global Core program
This provides the medical/surgical coverage and is designed to provide benefits for the professional fees associated with medical services when provided to a patient in the hospital, doctor's office, or in the home.
What is Blue Shield
This ______________ requiring health insurers to cover the diagnosis and treatment of autism spectrum disorders (ASD). Autism spectrum disorders are a class of pervasive developmental disorders (PDD) that are characterized by impaired verbal and nonverbal communication skills, poor social interaction, limited imaginative activity, and repetitive patterns of activities and behavior.
PA Autism Mandate
All calls must be documented in the tracking system within __________of the call ending and using either the specific ID# associated with the member or Provider NPI.
What is 10 minutes
HIPAA Authorization and Subrogation requests are received by Member Correspondence through two work streams:
1. Mailroom/Fax
2. Subrogation
Independence Blue Cross (Independence) and AmeriHealth New Jersey (AHNJ) have developed a Program that provides contraceptive coverage to members who are included in groups that have religious exemptions.
What is Safe Harbor Contraceptive Coverage