Provider Services Benefit Inquiries

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Provider Services Benefit Inquiries by Mind Map: Provider Services Benefit Inquiries

1. Confirm Member Plan Type

1.1. Enter ID Number into Neighborhood 360 to determine the system of record so the member's plan type can be confirmed

1.2. Medicaid plan member records are are stored in HealthRules

1.3. Medicaid-Medicare and Commercial plan member records are stored in Amisys

2. Confirm coverage and limitations for benefit in question

2.1. Check Medicaid Benefit Summaries for coverage and limitations for Medicaid plans

2.1.1. Check HealthRules claims to determine if the member ready had a service with a limit, such as an annual physical

2.2. Check INTEGRITY Benefit Coverage Summaries for coverage and limitations for Medicaid-Medicare plans

2.2.1. Check Amisys IQ0900 screen to determine if member already had services with a limit

2.3. Check Commercial Benefit Coverage Summaries for coverage and limitations for Commercial Plans

2.3.1. Check Amisys IQ0900 screen to determine if member already had services with a limit

2.4. If no result is found in the Benefit Coverage Summaries, check Benefit Clarification Guides

2.5. If no result is found in the Benefit Clarification Guides, consult Supervisor

3. Determine if Prior Authorization is Needed for the benefit in question

3.1. Access the appropriate tab, based on the member's plan type, of the Authorization Quick Reference Guide to determine if the benefit in question request a prior authorization

4. Determine if there a Member Cost associated with the benefit in question (Commercial plans only)

4.1. Access and search the appropriate Medical Benefit Cost Share document, based on the Commercial plan's variation, to determine what, if any out of pocket cost a member has, including a co-payment, coinsurance, deductible, and overall out of pocket maximum on the plan

4.1.1. Check the IQ0900 screen in Amisys to determine if the member has already met their annual deductible and/or out of pocket cost

5. Document and provide caller with a complete answer about the benefit in question

5.1. Document the inquiry and the components of the complete answer in the appropriate system and relay the to the caller

5.1.1. Component 1 of Complete Answer: Whether or not the service is covered

5.1.2. Component 2 of Complete Answer: Whether or not there are any limitations on the benefit and if so, whether or nor the member has already reached the benefit limit

5.1.3. Component 3 of Complete Answer: Whether or not the benefit requires a Prior Authorization

5.1.4. Component 4 of Complete Answer: Whether or not the member has any cost for the benefit