What are Connect
Always sound confident
Resolve our member's inquiry by owning it
I will set clear expectations
Never miss a service promise
Give exceptional service
100
The systems used to view and understand procedure and diagnosis codes.
What are EncoderPro and ICD-10 Data Maintenance?
100
The system used to search for medical policies and clinical guidelines.
What is OMPTA?
100
What Medicare Part A and Part B are used for.
What is Part A for hospitalization and Part B for professional services?
100
The system used to view Prescription coverage and claims.
What is esD?
200
The base 3 elements of HIPAA
What are Member Name, ID number, and Date of Birth?
200
Something that can be performed prior to a service to ensure that services will be covered. This is not a required process.
What is Pre-Determination?
200
The difference between a Grievance and an Appeal
What is a grievance tries to change benefits, while an appeal is a request for re-review of services, either for medical necessity, or administrative purposes?
200
The command used to view COB information.
What is CO(mbr ID),com ?
200
The four tiers in a four tier formulary list.
What are Generic, Preferred, Non-Preferred, and Specialty?
300
The type of policy in which you need a referral to see a specialist.
What is an HMO policy?
300
The fundamental things to know about Castlight and RBB.
What is Castlight provides an estimated cost for procedures to be done in a particular region? What is RBB could cause a member to be balance billed by an in-network provider if they bill above the RBB amount for the particular service (region-based).
300
EPHC and Blue Distinction
What is Enhanced Personal Health Care and Blue Distinction--Programs in which your doctors coordinate your care with other doctors. High Quality; Low Cost.
300
The Birthday Rule
What is a method to determine COB primacy? Determine whose birthday came first between the father and mother using just the month and day--that individual provides the primary insurance.
300
What you need to do to a doc number, and which system you use to look it up.
What is uncrunch it, and WCF?
400
The system used to access ID cards.
What is Clarity?
400
At least 4 different segments in the claim detail screen.
What are ML, CS, SP, GD, PN, IN, HS, H2, SI, MI, XR, DG?
400
The two options for AIM products.
What are UM and RQI?
400
AR/CR and what they're used for.
What is Accounts Receivable (used for collecting overpayment) and Cash Receipts (used for tracking the repayments)?
400
The system used to view correspondence on ITS claims.
What is Blue 2?
500
The difference between embedded and non-embedded policies.
What is embedded policies cause the individual accumulator to apply--the accumulator could be satisfied by any combination of family members, but an individual would never satisfy more than his or her individual amount. Non-embedded policies allow for a single individual to satisfy the entire family accumulator.
500
BAPS and what they're used for.
What are Benefit Administration Policies and for viewing policies for processing various types of benefits?
500
The two methods to view authorizations for medical services.
What is AF file or MAS Toolbar?
500
The system that houses inventory reports.
What is IRAMP?
500
The three message types, given in the order that they come, and listing who sends each type.
What is the SF, sent by the host, then the DF, sent by the home, then the RF, sent by the host?