New, forwarded, pending, suspended, completed or processing
What is the status of an application?
100
Inpatient care in hospitals, hospice care, home health care & Flu shots, Yearly wellness exams, Bone Density testing
What is known as Medicare A and B?
100
Refers to an HMO or HMO – POS plan that does not require the enrollee to receive a referral from his or her Primary Care Provider (PCP) to see a specialist.
What is an Open Access Plan?
100
A covered benefit that requires approval from the plan before the service can take place.
What is a Prior Authorization?
200
Lists open and outstanding items that are assigned to a specific single user.
What is a Worklist?
200
A verbal or written request to remove coverage prior to an effective date and prior to UHG sending enrollment info to CMS.
What is withdrawal?
200
Medicare Advantage Plan - Part C
What is the plan known to be offered by insurance companies and provides medical and prescription drug coverage?
200
Can either be a clinic or individual.
What is a PCP assignment?
200
A general question about plan benefits or coverage.
What is an Inquiry?
300
Provides the agent with direction on how to clear cache and cookies.
What is Optimize Performance (MIIM Navigation job aid)?
300
When a member is no longer entitled to either Medicare Part A and/or Part B benefits
What is disenrollment or termination?
300
Enacted December 8, 2003 to provide outpatient benefits through private plans beginning January 1, 2006.
What is Medicare Prescription Drug Improvement and Modernization Act?
300
Required by NICE plans when a PCP change is requested.
What is staying in the same PMG?
300
A decision has not been made about an authorization.
What is Pending Status?
400
Action allows agent to view benefits, billing, claims and save auto documentation and other information
What is Launch Account Summary?
400
Mr. John Smith calls into customer service to disenroll from a rider and instead of terminating the rider the entire plan is mistakenly terminated.
What is a Plan Error?
400
HMO plan with some benefits covered OON and no specialist referrals required with many plans.
What is Point of Service (POS) plan?
400
Specialty
Name
Provider ID
What is how to search for a provider on the COSMOS platform?
400
14 days
What is the standard Turn Around Time (TAT) for pre-service requests?
500
Provides direction for how to handle Category and Intent interactions.
What is the Category Intent Request Type Index?
500
A member requests to Attach or Detach the employer group from his account.
What is an Enrollment Dispute?
500
Employer Group plans that supplement Medicare coverage and can include Medicare Advantage, Medicare Supplement and Part D coverage.
What is Retiree Services?
500
Open/Closed/All field should remain Open
What is a PCP/Physician search in Nice?
500
The plan’s clinical department, or designated representatives of the plan’s clinical department.
Who makes the decision about Organization Determinations?