Quick Recap

PCGs are not responsible for obtaining the necessary referrals and precertifications while coordinating care.

When checking network status you collect the name, zip code and what else for the provider?

A fixed dollar amount that is the responsibility of the patient at the time of service is a.....

An Explanation of Benefits describes how a claim was processed and paid.

The "Office Visit" section of Qbase shows benefits for PCP sick office visits ONLY.

Pharmacy claims are processed in _______ so that the pharmacy will know if a drug is covered and how much it will cost.

People who have an established relationship with a PCP spend on average 30% less on healthcare.

The employer picks a PPO network to provide access and discounts to their employees.

The insurance employers purchase to protect their company from catastrophic loss due to high cost medical cases...

An OBGYN can only be designated as a member's PCP if they are pregnant.

Continuation of coverage offered after employment has ended is called...

PCPs are a medical home and can ensure you get the proper overall care.

What benefit would you quote for CPAP machines?

"Chiropractic visits are limited to 25 PCY..." is an example of...

The ______ network is the network that will provide members with their best benefit level.

The network that covers members when they are traveling temporarily outside their primary network area...

Who gathers the team of experts to design and build the health plan for self-insured groups?

Referrals must come from the designated PCP.

What is the legal entity that holds funds used to pay medical claims?

What disease process is involved when a member sees an oncologist?

Groups may include a provision in their benefits that prohibits traveling for care.

All plans offer an incentive when members have a referral to a specialist.

Because you work for Quantum, and have access to PHI, you can give it out to anyone who calls and asks for it.

Plan exceptions can only be made by the....

What percentage of the time do members incorrectly refer themselves to specialists?

A ___ can make a prescription drugs on-site. They are not chains and make expensive drugs that require special handling.

What benefit would you quote for botox injections?

What document outlines every detail of the plan and is known as the "Constitution" of the plan?

To increase a member's participation and ownership of their health some plans offer________.

To ensure members are at the correct level of care while inpatient the UR nurse performs daily...

Members can use OON/PAI if services are not offered by an INN physician.

How many pieces of information are you required to get from a member or provider prior to giving out PHI?

PHI stands for "Personal Health Information".

If you have a clinical question that requires the assistance of a nurse in the POD, you ask the____ first.

For what purposes can covered entities use PHI?

Self-funded plans are governed by ____ laws which are federally regulated.

A savings account that can be funded by both the employer and the member to help pay for healthcare costs...

What kind of benefits would you quote for a sick visit with a pediatrician?

Which privacy regulation permits covered entities to use and disclose PHI?

Drugs on the formulary can be both ___ and ____.

A member calls and has a PCG condition. They are on break at work. You should still put in a PCG referral in PIVIT.

Care Coordinators can update a member's home address in PIVIT.

Healthcare Bluebook is a pricing transparency tool that allows members to compare prices and shop to find the best price

The plan sponsor is the....

Cases that exceed $100,000 in paid claims are considered...

What is a CPT code?

Tiered networks are usually used by hospital systems.

If a precert is not required but we want to make sure something is medically necessary and covered we build...

What does the "atom symbol" next to a doctor's name in PIVIT mean?

What does U&C stand for?

To determine which plan is primary for minor dependents when they are on both mom and dad's plan the TPA uses...

If a member calls and says they are thinking of "ending it all" what should you do?

If the ex-employee chooses NOT to take advantage of COBRA, the rest of their family may still participate.

What does PPO stand for?

DME stands for Durable Medical Equipment.

You create a ____ when the PCP notifies us that they are sending a member to a specialist.

Approval for OON/PAI can only be made if the plan offers this provision.

A group of doctors, hospitals and other providers that are contracted for services at a lower than usual rate...