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Jeremy Stanly. HumanaOne Benefits . Humana. Verification of Benefits Training Agenda. Landing Page Affordable Care Act compliant – what does that mean Essential Health Benefits Benefit Grids Vision Dental PCP ID Card Cost Sharing Deductibles Common Transfer Numbers.

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HumanaOne Benefits


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verification of benefits training agenda
Verification of Benefits Training Agenda
  • Landing Page
  • Affordable Care Act compliant – what does that mean
  • Essential Health Benefits
  • Benefit Grids
  • Vision
  • Dental
  • PCP
  • ID Card
  • Cost Sharing
  • Deductibles
  • Common Transfer Numbers
humana one individual line of business
Humana One – Individual Line of Business
  • What is it- HumanaOne is for individuals who purchase their own insurance. They are not affiliated with a group or programs such as Medicaid.
landing page
Landing Page
  • The landing page is the first place you will be taken when receiving a member call.
  • The next slide will show what the Landing Page looks like.

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landing page1
Landing Page

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affordable care act compliant
Affordable Care Act Compliant

What does this mean?

  • The benefits that you will be quoting are plans that went into effect on or after 1/1/14 is considered to be ACA compliant.
  • There are 10 essential health benefits that must be included in all of these plans.
  • Mentor Doc: Essential Health Benefits Overview
affordable care act compliant1
Affordable Care Act Compliant
  • The ACA compliant plans fall under one of four metallic tiers, and are named as such:
  • Platinum
  • Gold
  • Silver
  • Bronze
  • An example plan name would be: FL HMO Premier 80 IMM Silver 1 Connect Silver

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terms
Terms
  • Deductible- The portion of the covered member’s health care expenses that must be paid out of pocket before the member’s plan begins paying its share
  • Coinsurance- A percentage of health care costs for which the member is responsible under the member’s health benefit policy. For example, a member might pay for 20 percent of the cost of a service, with the health coverage policy paying the remaining cost
  • Copayment-A fixed amount of health care costs for which the member is responsible under the member’s health benefit policy. For example, a member might pay $15 for each visit to a physician, with the health coverage policy paying the remaining cost.

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terms1
Terms
  • Maximum Out of Pocket-The amount a member is required to pay for treatment or services.

Example: You will see something like this maybe $5000/$6500

The $5000 is the deductible and the $6500 is the Maximum Out of Pocket (Moop)

  • Cost Sharing- The portion of the deductible or out of pocket that the member may get a reduction on due to income levels.

Example: A member may have a deductible of $5,000, but receive a cost share discount to bring their deductible down to $3500 based off of their income level.

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benefit grids
Benefit Grids
  • Benefit grids are where the member’s benefit information comes from.
  • To populate these grids, in CCP click the benefits tab:
benefit grids2
Benefit Grids
  • The slide prior shows what the benefit tab looks like.
  • The grid then will populate in mentor:
benefit grids3
Benefit Grids
  • The name of the member’s plan is the hyperlink that you actually click to get into the grid:
benefit grids4
Benefit Grids
  • On the bottom there are tabs where the medical benefits and the Pediatric Vision benefits are available.
  • The benefit tab is what is used most often, unless the member has a question about Pediatric Vision
deductibles
Deductibles
  • Some members may have their deductibles populate for you in CCP on the benefits tab:

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deductibles1
Deductibles
  • Some members may qualify for cost share through the federal government.
  • Cost share is where the government picks up a portion of the members deductible. For example if the plan calls for a $4600 deductible, with cost sharing it may drop it to $2500.
  • To locate the cost share go back to the landing page and hover over the member details button at the top. A drop down will appear and click on Cost Share.

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locating cost share
Locating Cost Share

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locating cost share1
Locating Cost Share

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pediatric vision
Pediatric Vision

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pediatric vision1
Pediatric Vision

For questions regarding Pediatric Vision:

  • Use the benefit grid the same way you learned how to quote the medical benefits.

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dental
Dental

Some members may have a dental benefit.

  • To find if a member has one of these you would check on the Member tab of CCP.

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dental1
Dental
  • This plan has a CB next to it, so that would be a warm transfer to the Dental CompBenefits area at 855-204-4929.
  • For Dental Plans that do not have a CB, warm transfer to 877-282-5654

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slide24
PCP
  • To verify who a member’s PCP is (primary care physician) go to the benefits tab again.
  • Click the PCP tab:
  • The types of providers that can be PCPs are; Family Practice, General Practitioners, OBGYN’s, Internal Medicine and Pediatricians
pcp changes1
PCP Changes
  • To assist a member with a PCP change go to the PCP tab on the benefits screen
  • Go to physician finder and make sure the PCP is in network.
  • To get the physician ID click on the physician’s name
  • Then click on the hyperlink that says “more” under Locations and Affiliations.
  • The PCP number appears.
  • The following slides will show you the process.
  • If the member is a 1/1/14 effective date you can backdate the PCP effective date. The change will take 24 hours to take effect in CCP.

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pcp changes2
PCP Changes

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pcp changes3
PCP Changes

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pcp changes4
PCP Changes

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pcp change
PCP Change
  • If for some reason the change doesn’t work in CCP then follow the below process:
  • All Primary Care Physician (PCP) Changes should be made in CCP.  NOTE: If the network says FL HMO Premier, it is not a true HMO and does not require a PCP.
  • If you are unable to update the PCP in CCP because the system is giving you an error message, please use the following scripting.

Scripting:

“I’ll send a request for your PCP change now, you will be getting a new ID in an estimated 10-14 business days. What is the best number to reach you at if we have any additional questions or concerns with your new choice?”

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pcp change1
PCP Change
  • Then please document your inquiry with the following information and send it to the tank below.
  • Please include in your notes the following information, all of which can be found in Physician Finder Plus (PFP) except for the member’s phone #:
  • Physician’s Name:
  • Physician’s Address:
  • CAS #:
  • Member’s Call Back Phone #:

After filling out the above information, send your inquiry to:

  • Service Center: Green Bay
  • Department: INDALLS Calls
  • Team: PCP Update
  • User: Blank

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id cards
ID Cards
  • For ID card orders please advise the member to go to Humana.com and they can view or print their ID Cards.
  • If they are having problems doing this assure them that their cards are on the way.
  • In the mean time double check the member’s effective date to be 1/1/14.
  • Also inform them of their member ID and their Group #. Those are what they will need to attain care from their provider.
transfer types
Transfer Types

Some calls may require you to transfer to other departments:

  • For more in depth medical benefit or referral questions please cold transfer to HumanaOne claims and benefits at 855-477-2418
  • For any pharmacy claim and benefit questions transfer to 877-832-4229
  • For member calls where they have a procedure scheduled and want to know if authorization is needed, transfer to our Clinical Intake Team (CIT) 800-523-0023
call logging
Call Logging
  • When logging the benefits please copy verbatim from the grid, and paste the benefit into your free text. If multiple benefits are given then paste all the benefits into one CCP Inquiry.
  • Your CRD’s for the call will be:

Category- VOB

Reason- (type of benefit) such as Preventive

Disposition- (what you did) such as info given

call logging1
Call Logging

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technology errors
Technology Errors

If for some reason there is an error in CCP or Mentor where the information is not populating or you get an actual error of some kind.

  • Please send a screen shot as well as a description of the error to Dana Vandenlangenberg (Dvandenlangenberg@humana.com)

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questions
Questions???

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