Introduction to GPS
It is a self-service interactive voice response telephone system, which is used to receive calls. Give the complete name.
Aetna Voice Advantage (AVA)
In what section can you find the Definition of Dependents?
Additional Benefit Coverage
What are the sub product type of EPO?
Aetna Select
Elect Choice
Managed Choice
We refer to this network as the broad network or direct network.
Aetna Health Plan Network (AHP)
Give the spiel if you get no response twice to your greeting.
Caller, I can’t hear you and am disconnecting the call. Please use Availity or call back if you still need help.
Give the 2 information needed to validate the provider's account.
TIN/NPI
Name of the provider
What does CSA stand for?
Control-Suffix-Account
What is the difference between Direct access and Open access?
Direct Access is built in and waives referrals in certain situations, Open Access is added on and waives the referral requirement completely
Give at least 2 NAP vendors.
Beech Street
First Health
Galaxy Health Network
Integrated Health Plan
MultiPlan
Omniclaim
Three Rivers
What are the two types of service requests?
Automatic Service Requests
Manual Service Requests
Give the 3 information needed to validate the member's account
Member's ID
Name
Date of Birth
What is the difference between Fully funded and Self funded in terms of legislation?
Federal Legislation
State Legislation
What are the sub product type of Traditional Choice/Indemnity?
Comprehensive Medical
Major
Basic
What are the three types of care impacted by Institutes of Quality (IOQ) narrow network facilities?
Bariatric Surgery
Cardiac Care
Orthopedic Surgery
How will you document the call in GPS for No voice with call/Ghost call/Hold music upon greeting?
Fully validated - Go to the Caller Hang-up/Disconnect SR to document
No validation - No documentation needed.
Give at least 3 Specialty Calls that we do not handle.
Aetna Dental (non-facility)
Aetna Affiliated Groups (i.e., Meritain, Aetna Student Health (ASH) and Aetna Signature Health (ASA)
Aetna Voluntary (formerly Strategic Resource Company (SRC)
California HMO members who live in California
Individual and Family Plans (IFP)
Medicare NextGen (MNG)
Give at least 4 types of dependents may be included under plan coverage documents for eligibility?
Subscriber's spouse
Dependent children under the plan's limiting age
Foster children
Grandchildren
Stepchildren
Domestic partners
What is the sub product type of HMO on ACAS?
HMO
QPOS
Health Network Only
Health Network Option
What is Concentric Model?
A Concentric style plan has one level of in-network/preferred benefits or maximum savings benefits only.
This means a member must see a provider within their narrow network. If they don't, they'll receive out-of-network benefits if available or no coverage at all.
Give 3 examples of case comments.
Clinical Policy Bulletins (CPBs)
Procedure codes, HCPC codes, procedure name, diagnosis codes
Not covered benefits (document the service/procedure that's not covered)
Keeping the commitment (KTC)
Escalated call details
Give at least 3 office keys we DO NOT handle.
039 - SRC
128 - SRC
153 - JCA
415 - TRS
753 - TRS
315 - ASH
Give 3 examples of why a person's coverage may terminate.
Subscriber's employment terminates
Plan sponsor's contract terminates
Status change and are no longer eligible (i.e., divorce, etc.)
Dependent child reaches the limiting age of the plan
Give the EPDB Network of all Aetna Products.
Aetna Select - MEPO
Elect Choice - MEPO
Managed Choice - MC
Aetna Choice POS II - MC
PPO - MPPO
Indemnity - No networks
HMO on ACAS - MHMO
Differentiate all 4 tier level
Tier 1 - Designated performance network hospitals and physicians
Tier 2 - Designated performance network hospitals and physicians at custom sites (sister sites)
Tier 3 - All other Aetna in-network hospitals and physicians
Tier 4 - Out-of-network hospitals and physicians
What steps must CSRs complete as part of properly closing a customer call?