Post on 14-Dec-2015
Jeremy StanlyHumanaOne Benefits
Humana
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• 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
Verification of Benefits Training Agenda
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• What is it- HumanaOne is for individuals who purchase their own insurance. They are not affiliated with a group or programs such as Medicaid.
Humana One – Individual Line of Business
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• 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.
Landing Page
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Landing Page
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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 Compliant
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• The ACA compliant plans fall under one of four metallic tiers, and are named as such:
Platinum GoldSilverBronze
• An example plan name would be: FL HMO Premier 80 IMM Silver 1 Connect Silver
Affordable Care Act Compliant
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• 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.
Terms
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• 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.
Terms
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• Benefit grids are where the member’s benefit information comes from.
• To populate these grids, in CCP click the benefits tab:
Benefit Grids
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Benefit Grids
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• The slide prior shows what the benefit tab looks like. • The grid then will populate in mentor:
Benefit Grids
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• The name of the member’s plan is the hyperlink that you actually click to get into the grid:
Benefit Grids
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• 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
Benefit Grids
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Benefit Grids
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• Some members may have their deductibles populate for you in CCP on the benefits tab:
Deductibles
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• 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.
Deductibles
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Locating Cost Share
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Locating Cost Share
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Pediatric Vision
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For questions regarding Pediatric Vision:
• Use the benefit grid the same way you learned how to quote the medical benefits.
Pediatric Vision
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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.
Dental
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• 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
Dental
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• 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
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PCP Changes
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• 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.
PCP Changes
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PCP Changes
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PCP Changes
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PCP Changes
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• 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?”•
PCP Change
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• 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
PCP Change
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• 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.
ID Cards
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ID Cards
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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
Transfer Types
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• 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- VOBReason- (type of benefit) such as PreventiveDisposition- (what you did) such as info given
Call Logging
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Call Logging
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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)
Technology Errors
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