Delegation/Capitation
Quoting Benefits
Referral/Authorizations
Providers
Claims
100
Fee-for-Service

What is a set payment amount for services rendered?

100

once in AARPMedicarePlans.com, used to give detailed benefits

What is Evidence of Coverage (EOC)?

100

are currently required for all plans on the NICE claims system

What are referrals?

100

counties in Arizona have PSPs

What is Maricopa and Pinal?

100

If the claim is not found in account summary, you would then need to

What is verify delegation?

200

The terms (??) and (??) go hand in hand

What is Financial Risk and Capitation?

200

amount calculations are based on the Contracted fee or Medicare approved amounts for each service, and not total claim amount.

What is Coinsurance?

200

managed by the reviewing entity (plan or PMG)

What is authorization?

200

change requires specific information to be documented in the Tier 1 comments

What is Retro PCP Change?

200

To get all the information about a claim's status, use the (?????) in the Summary section

What is Claims Note Box?

300

There are primarily three capitation arrangements

What is global capitation, split (partial) capitation and share capitation?

300

Benefit Period

What is used to measure the member's use of hospital and SNF services?

300

required for gatekeeper plans, except in emergencies

What is referral?
300
3 available search options for NICE

What is facility, medical group, and physician

300

received Denial code DK

What is Not Medically Necessary?

400

Two places where you can verify delegation

What is summary and plan tab?

400

The Benefits Inquiries - Index job aid includes a (???) section that includes helpful information and links to related resources

What is frequently asked questions?

400

list where you can verify if an authorization is needed

What is Prior Notification List?

400

PSPs consist of what 2 states

What is Arizona and California?

400

received Claims Code Pendinging 1P

What is Potential Duplicate?