Purple
Difference between providers' full fee and what the plan allows (only happens for out of network).
Balanced Billing
TPA
There can be specific instances written into the _____, in which a plan will allow an Out of Network provider to be paid as if they are In Network.
SPD (Summary Plan Details)
When quoting benefits for Outpatient Surgery. Who are the 2 providers we should be checking the network status on.
Facility
Surgeon
The fixed dollar amount that is the responsibility of the member/family to pay before the plan starts to pay a certain percentage.
Deductible
These are Not covered under the plan.
Exclusion
Manages pharmacy benefits.
PBM
A fixed dollar amount that is the responsibility of the member/family to pay before the plan will start paying 100% of covered INN services.
Out of Pocket Maximum
hired by the employer to be customer service and medical management of the benefit plan.
Quantum Health
When building a Pre-Cert for an Outpatient MRI. What are the 4 Items needed?
(Not including the Date of Service)
CPT Code
Diagnosis Code
Ordering Provider
Facility
Dollar amount or visit limit on a benefit.
Insurance that protects the employer from catastrophic loss due to high-cost medical claims.
Stop Loss Carrier
The network that covers members when they are traveling or temporarily outside of their home area.
Wrap Network
Date of Service
Total Charged Amount
Provider Name
Name of the document that outlines every detail of the plan. Also known as the "constitution of the plan".
SPD (Summary Plan Description)
The rate insurance bases the allowed amount on when someone goes out of network.
Usual & Customary
Controls plan design, determines coverage - these plans are one size fits all, Provides customer service and medical management.
Carrier Model
What are the 3 pieces of billing information needed to verify a provider is INN.
Provider Name
Address
NPI / Tax ID
A group of doctors, hospitals, and other healthcare providers that are contracted to offer their services for lower than their usual rate.
Network
What are the 3 places/ways to find a claim.
TPA Website
Members Website
Internal claim system
Basing out of network allowed amounts on Medicare rates instead of U&C.
Medicare Allowable
Coordination of Benefits
People who have an established care with a PCP on average save about ____ % on their health care.
30%
These can affect members eligibility.
Job Status, Hours worked, Marriage Status, Domestic Partner Status, and Dependent Status
The network that is going to give the member their BEST benefit.
Primary Network