Benefits
What are the 3 elements of a benefits call
Copay, Provider Network Status, and Authorization/Referral Requirements.
This department is a wellness and incentives program. It encourages members to improve their health by doing things like going to a fitness facility and getting a preventive screening.
Go365
Which department do you send claims suspected of medical fraud in CRM?
CRU
This report shows the history of premium payments made, including the account balance.
Billing Audit
Use this tool to locate pharmacy
Pharmacy Finder
Who is the vendor for acupuncture
Tivity
This department handles the treatment of morbid obesity
RSO Bariatric & Gender Reassignment
Proof of loss, is the time allowed for a claim submitted to Humana to receive reimbursement of expenses is also called what?
Bonus: How Long?
Timely Filing
Bonus: 12 Months
This letter is sent to members to verify a member’s current monthly plan premium and/or a member’s plan premium.
This tool provides real-time claim details, including any error codes
RxNova Call Connect
True or False: Members pay the highest cost share when visiting the ER and placed in observation.
True
This preauthorization department specializes in Home Health Care for Arizona
Tango
True or False: PARE providers can balance bill the member for any charges over the Humana allowable and member responsibility.
True
What is the Classification/Intent for member who received coupon book with discrepancy in premium amount due to LEP.
Billing / LEP Premium
Humana creates this for members who want a summary of their drug benefit utilization
Claims Detail Report
What is the term or acronym that identifies the plan type along with the group number
Benefit Sequence Number or BSN
This department investigates claims paid by Humana that are identified as accident and injury related.
Claims Cost Management (CCM)/Subrogation
What is the appeal timeframe for medical claims?
65 Days
Where do you send case for member's who want to opt out of the DEAA?
What is Centerwell Pharmacy reimbursement timeframe.
30 Days
This term refers to the appropriate and necessary treatment of patient illness/injury according to accepted standards of medical practice and CHAMPUS. The decision is made by the health plan's medical review staff
Medically Necessary
Only supervisors are authorized to transfer a call to this area as it relates to provider has contacted Humana several times with no resolution about their Network Status
Centralized Provider Relations
Which department do you transfer a hospice claim that has eob attached?
Coordination of Benefits
What do you do when the member receives a communication that SSA/RRB deductions have been stopped.
The letter and refund check are due to an audit of claims processed while the member was under hospice care.
Hospice Audit Letter