TOOLS
This is used as an emulator of members' online accounts.
Smarthelp / APP / Associate Productivity Platform
Define precertification.
Answer 2: Process of checking whether a service requires pre-authorization.
Give at least 3 claim statuses.
Open / Pending
Paid
Denied / Rejected
Adjusted
(Any three of the above)
Define what PCP is as if explaining to your member.
"PCP stands for Primary Care Provider..."
Trainer Steph will determine if you're correct.
What is BlueSquare used for?
Viewing ITS Claims
Booklet containing all the details of a member's medical benefits. It also serves as a contract between the member and Anthem, outlining the terms of their medical benefits policy.
EOC / Evidence of Coverage
What is the KM Article for claim research review.
Claims Research Process - SC
3 Types of Providers
Professional
Facility
Ancillary
WCF
Claim images / hard copies can be viewed using this tool.
Guess the movie
🦖🏞️🚙
Define what Home and Host Plans are.
The home plan is the member’s main insurance plan. It’s the state where their benefits, rules, and costs come from.
The host plan is the plan in the state where the member actually gets medical care.
Give 2 tools and/or tasks you can use to locate providers and confirm whether they are in network.
Solution Central
Solution Central - Provider Task
Solution Central - Research Provider under Provider Task
FindCare
CA Mainframe
Any of the above.
Supplementary tool just incase solution central benefit and cost task is not working
FOBS
Name at least 2 tools used to view Authorizations/ Referrals
Member360
ACMP
Solution Central
What does ITS stand for?
Inter-Plan Teleprocessing System
Define Referral and how do we check if it is required?
OBIS
We use this tool for NY Kernel
What procedure is this code: 99242?
OFFICE/OTHER CONSULTATION; EXPANDED PROBLEM FOCUSED HISTORY; ** EXCEPTION
(as shown in the LookUp Code)
Guess the movie
🧙♂️💍🌋
Differentiate Transition of Care from Continuity of Care
TOC: Allows a new member to keep seeing their current out‑of‑network provider for a short time (up to 90 days) while they switch to an in‑network doctor.
COC: Allows a member to finish treatment with a provider who is leaving the network or is already out‑of‑network before moving to an in‑network doctor.