MHK
It is also called "the home of appeal cases"?
MHK
Why we need to use Medicare Stars Central Portal?
To retrieve or obtain a copy of a member's Evidence of Coverage (EOC).
What is MedCompass?
A system that houses precertification details and denial letters.
The member, their authorized representative, a physician, or an entity with an appealable interest has how many days from the date on the pre-certification denial letter to submit their request for reconsideration?
60 Days
What is the Turn around time for Pre-Authorization?
14 Days
This is a Field where you can identifies who submitted the appeal?
Requestor Section
TRUE or FALSE. During the launch process are we required to attach the EOC to every appeal case in MHK.
True we need to attached the EOC to every appeal case in MHK.
Where you can obtain reviewing clinician's notes?
Clinician Review
Aetna has how many days to make a redetermination on the standard pre-service appeal request.
30 days (this includes holidays and weekends)
What plan is one of the most affordable types of health insurance. While it may have coinsurances, it generally has lower premiums and deductibles. It also often has fixed copays for doctor visits. It’s a good choice if you’re on a tight budget and don’t have many health issues?
Health Maintenance Organization (HMO) plan
This section is used to document additional information needed such as receipt of or need for Medical Records.
Additional Info Section
It enables us to pinpoint their exact plan.
Clue: It consist of Letter followed by 4 numbers and the series of 3 Numbers.
Contract-PBP
Where you can Access Service Authorizations?
Clue: Precertification
Utilization Management
Aetna has how many Hours to make a redetermination on the Expedited pre-service appeal request.
72 hours (this includes nights, holidays, and weekends)
Which plan has higher premiums than an HMO. But this plan lets you see in-network and out-of-network doctors without referrals. Your costs for in-network items and services are typically lower than out-of-network?
Preferred Provider Organization (PPO)
This is where you indicate whether you have a Valid Appeal and update the case status using the Status and Status Reason fields.
Case work Section
What is the system that houses Aetna Medicare plan and member information?
Medicare Stars Central Portal
Where you can Locate a list of all plan networks?
Insurance
If good cause is established when does the appeal processing timeframe start?
Begins on the date the plan receives that information.
IRE Stands for?
Independent Review Entity
This is where all the historical dates are captured and recorded for a case?
History Tab
YES or NO. Can we open all kinds of plans in Medicare Stars Central Portal.
NO
Limitations: Group PLAN (You can use GPS)
It is used to determine provider participation.
Plan Networks
TRUE or FALSE. Appointment of Representative (AOR) form allows an enrollee to designate another person to act on their behalf for up to 12 months.
TRUE
It is defined as a negative attitude toward aging and the age accompanied by the systematic stereotyping and discrimination against people because they are old.
Ageism