M&R Core
Tools
Glossary
HIPAA
EASY
100

M&R means?

Medicare and Retirement

100

Tool used in viewing member's diagnosis and Medical Prior Authorization status

ICUE

100

The document that describes any changes to the Member benefits, coverage, costs, premiums and/or service area that will be effective in the new plan contract year.

Annual Notice of Change (ANOC)

100

A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. 

HIPAA

100

A third-party caller should obtain __ when speaking on the member's behalf. 

Verbal Authorization

200

Also known as Medicare Advantage

Medicare Part C

200

Houses all SOPs and jobaids

Knowledge Central

200

A set time each fall when Medicare Advantage (MA) AND Medicare prescription drug coverage Members can change their health or drug plans or switch to Original Medicare.

Annual Election Period (AEP)

200

Examples of Caller Types 

Member 

Authorized Representative

POA/ Guardian / Conservator

Trustee

Attorney

Broker

Employer Group

Foster Parent (C&S Only)

Insurance Company

Internal Caller

Media Representative

Parent / Guardian of a Minor

Provider

SHIP Counselor

Third Party- Others

Federal / State Regulator (SPAP, CMS, State Medicaid Agency

200
Medicare Claim Number is also known as: 

HICN Number

300

A Federal insurance program that caters individuals over 65years old and/or having long term disabilities

Medicare

300

Tool used in scheduling HouseCalls

PCSS Tool

300

A department within the Plan responsible for answering questions about membership, benefits, grievances, and appeals.

Customer Service

300

True or False: We are allowed to disclose general information about the member's account if the caller is not the member

True

300

The amount paid out of pocket by the policy holder before an insurance provider will pay any expenses.

Deductible

400

Medicare Open Enrollment Period

October 15-December 7

400

A tool used to locate existing HouseCalls appointments or missed HouseCalls.

Housecall/Member Status (optum.com

400

A list of prescription drugs covered by the plan. The list includes both brand name and generic drugs.

Formulary

400

True or False: A new email address cannot be added without the member’s verbal consent.

True (Ref KM1007997)

400

Intent used if member is requesting a comprehensive formulary list

Member materials

500

A Federal agency who is responsible for the oversight of Medicare and Medicaid

CMS- Center for Medicare and Medicaid Services

500

Tool used in punching auxes according to the given schedule. 

Genesys

500

Refer to Non-Contracted Provider

OON (Out of Network)

500

True or False: If the caller is a broker, member does not need to be present to provide permission; the broker only needs to verbally attest that they have received permission from the member.

True (Ref KM1004106)

500

Gaps in care

Next Best Action (NBA)