SOP/ SPAS
Caller wants to know if they can request a POLC. You look to this SPA for guidance on the process.
What is HIPAA Advocacy
Member is retired, 65, and has UHC and Medicare. Name the primary insurance plan.
Medicare
We send this to member's when they want to submit an FSA or HRA claim
Ezcomm link FSA claim submission form or HRA claim submission form
UHC requests COB to updated minimally this frequency.
Annually or when life changes happen that impact COB
Hold time for a SME before disconnecting.
3 MINUTES
SPA that offers guidance on what to do if member asks for your first and last name.
Building Trust Through Advocacy
Medicare is primary and will cover the service, do we require a prior auth?
No, if Medicare pays, we will process and pay per member's benefit with is
The time frame, after the year, that the member can still use their FSA funds into the new year is called:
Grace Period
Connect here when a member's COBRA is expiring, they are wanting short term insurance, and their employer plan didn't allow for induvial conversion.
Golden Rule
Number of occurrences you can receive before getting a CAP.
3 the fourth would be an initial CAP.
Member has a Harvard Pilgrim Plan and none of the providers are highlighting. This SPA offers manual matching guidance. SPA and section name
Provider Referral Advocacy > Identifying Harvard Pilgrim INN Providers - ISET
When we won't duplicate the payment Medicare would have paid had the member opted for Medicare.
Medicare Non-Duplication of payment
The area in CAMS that shows if an account has automatic payments enabled.
Coordinated Payments box under the spending account tab.
Member states they have a handicapped child, but our systems do not yet reflect handicapped status, and they stated they submitted the letter. We check for letter here.
MCR Disabled Dependent
The ARTT of hold stands for
A: Ask the member if you can place them on hold
R: give them a Reason
T: give them a Time frame
T: and Thank them when returning
This SPA offers guidance on how to connect member to the team that assists transgender persons. SPA and section
Benefits and Coverage Advocacy > Gender Identity Support Team
SPA that provides guidance on what to do if a Medicare member wants to know how we will cover hearing aids that Medicare won't cover.
Eligibility Advocacy > Medicare Non-Covered Services
Play as Plan Pays vs Standard Processing
Pay as Plan Pays means that only claims that have processed through the medical policy and have an eligible patient responsibility are reimbursable. Standard means the account follows standard IRS guidelines.
Not calling a member back after a call drops, Prolonged hold time, and excessive personal use are examples of.
Call Avoidance
Number of occurrences you can receive before getting a CAP.
3 and the 4th would lead to a CAP being initiated.
SPA that offers guidance on whether a member can have surgery in a hospital. SPA and section
Notification Advocacy > Outpatient Surgery
The process by which Medicare, as the primary payer, automatically forwards Medicare Part A (hospital) and Part B (medical), including durable medical equipment (DME), claims to a secondary payer for processing.
Medicare Crossover
Member calls asking what expenses are eligible. We advise:
The IRS decides what expenses can be paid using a Health Care and Dependent Care FSA. Although, your employer may limit the list.
Individual Conversion is
An option for some participants after the individual's COBRA/State Continuation coverage expires.
Not calling a member back after a call drops, Prolonged hold time, and excessive personal use are examples of.
Call Avoidance