Notes

PRODUCT TRAINING
CITRIx ACCESS:
c930549 Join@618
c944735 Vem@1989

username: C944735
pw:Vemc1989

OMNI ACCESS:
tcsr77
rules

sample id:

r07560472
r07441144 darlene yu
r07273008 yalda nash
add member

dep and groups > business tools
pcp 2 card
card 2

GLOSSATY FOR Kb:
http://kb.healthnet.com/display/2/index.aspx?tab=browse&c=&cpc=&cid=&cat=&catURL=&r=0.8516989

contact center tool:
https://hnc.healthnet.com/documents/departments/hnca/business_tools/customer_call_center_tools


Federal Employee Program - Adding a newborn
59276
Customer Service Document
6962




PRODUCT TRAINING
DAY 1:
ACA

INTRANET VS INTERNET:
INTERNET - available to everyine provied that they have access to gina network


INTRANET privately maintianed a private computer network that can be
privately secured
only authorized individual hasve access

cids: citrix id -


GREETING - 5 SEC - COMPANY - NAME
- ACCURATE AND COMPLETE -
read the disclaimer + foiotnotes

RESOLUTION

CLOSING:
complete documentation? reason of call // indicate foot notes//
is ther anything else?
clising- thank the Cx and say good bye//


never repeat the
some of the information you porided did not match

CSR - Cost Sharing Reduction / share expense from the Government and Provate institution


TOOLS :
- citrix
- kb
- lutos notes
- abs



Medicard and Medicare

APTC - Advance Premium Tax Credit -
subsidy provided by the governemtn
PHI - Protected Health Information

ACA - Affordable Care Ac
The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health

HMO -health maintenance organization

health maintenance organization (HMO) is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities in the United States and acts as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis.

PPO - Preferred Provider Organizat
A PPO is a Preferred Provider Organization within the framework of the managed care health insurance industry. A PPO is a group of doctors, hospitals, and other health care providers who create a network and negotiate predetermined fees with a given health insurance carrier

PCP - Prmary CAre Physician
A health insurance term used to describe a physician who is responsible and coordinates all of a patient's care in a managed care system like a preferred provider organization (PPO) or health maintenance organization (HMO). The primary care physician is the primary point of contact with the insured patient and acts as a gatekeeper controlling the insured's access to health care through the insurer.

Capitation
A reimbursement approach wherein a health care provider agrees to make a specific set of services available to a covered individual for a fixed payment, regardless of how many services that person receives. This approach is often used by health maintenance Organizations and usually means that a set amount is paid to the provider each month for each enrolled person. "Capitation" also is used to mean the total cost of providing a specified set of health services to the average HMO member for a specific period of time, usually a monthly period. This amount becomes the basis for determining the premiums (rates) that the HMO charges its members. A per-member, monthly payment to a provider that covers contracted services and is paid in advance of its delivery. In essence, a provider agrees to provide specified services to plan members for this fixed, predetermined payment for a specified length of time (usually a year), regardless of how many times the member uses the service. The rate can be fixed for all members or it can be adjusted for the age and sex of the member, based on actuarial projections of medical utilization.



PPG - Primary Physician Group

IFP - Individual Family Plan

EOC - Emergency operation Center

SBC - summary of Benifits

SOB - schedule of benifits

HNCA - Health Net Life Insurance Company

HNOR - Health net health plan of Oregon

HNL - HEALTH INSURANCE COMPNAY

HIPAA - HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

SHOP
PHI -
PII
MEMBER
SUBSCRIBE
DEPENDED
KB
DEDUCTIBLE
CO-PAYMENT
CO-INSURANCE
OOPM
PROVIDER
CSR
MAA - maximum allowable amount
CAPITATION
PLAN CONTRACTED RATE
BILLED AMOUNT
DIFFERENCE
IEX - on exchange oruce ti amrket that is provided by the governemnts
IFP - oof exchange
- purchase from private insurance


10 ESSENTIAL NEEDS

- Emergency needs
-Maternity services and Newborn care
- Rehabilitative and Habiliative
-mental Health and Substance abuse
- Prevent ive Wellness and Chronic disease management
- Hospitalization
- Laboratory services
- Predictric services
- ambulatory services
- Prescription drugs


HMO (Health Maintenance Organization)-requires PCP, PPO and No deductible, if in case the PCP is not available or decline service, the member should be refer to a PCP who is in network.
-is a pre-paid healthcare plan which provides and arranges basic health
-PREVIOUSLY PAID SERVICES.

Capitation- Negotiated amount between Health Net and the medical group where services is paid per member per month.
PCP- Assumes over all responsibility for the health of a member.
-also in charged of referral& providing prior authorization.
PPG- Participating Physician Group (medical Group)
-member's choice
-group of physicians contracted to Health Net
Access to care: PCP and PPG. (not all medical groups require a pcp)
Exception
Claims:
California: Capitation, Professional services are w/ Capitation

Arizona: FFS (Fee for service), professional service are paid on a contracted rate & there are required to bill Health Net.

Models:
1.) Group Model- is a group of doctors & providers own insurance.
- usually stay in one building (Ex. Kaisers)
2.) Network Group-Health Net

HMO members -> pcp/ppg -> pcp attends the care -> HN pays portion and members pays co payment and co insurance -> in case pcp refer, pcp provides referral to a pcp in network -> in case of out network make sure pcp is in contract with hn doesn't matter if ppg is not in contract.

CA Direct Network- When no Medical Group/PPG is available, Health Net assumes responsibility as the PPG/Medical group.
*eligibility-Member lives in a remote area and No PPG available in their area accepts New patients.

AZ HMO Open Access:
* Not required for PCP
*Member's can self-refer to any contracted specialist within the network.
*PPG required
*Open access to members MUST OBTAIN doctor's order to receive laboratory, Xray,PT & other services they may not self-refer
*claim in FFS
* There is plan deductible.

TIER 2 (PPO) Preferred provider organization
-self refer, deductible applies, provider lower co-payment & co-insurance to In-Network providers., If member went OON; greater OOPM responsibility to access type of care, doctors & hospitals agree to specific contract arrangements but are only paid FFS,
-Capitation doesn't apply.
-Access to care: PCP contracted to HN. No need to have PPG.

MAA (Maximum Allowable Amount)- Amount on which Health Net will only reimburse for covered services for OON. -reimbursement to the provider.

TIER 3 (OON) Out of Network
-Indemnity Plan-FFS, member may seek services to any licensed physician of there choice as long as the PCP is contracted.
Claims: Member will pay first before filing a reimbursement. Members must meet the deductible before they can get reimbursement.
-No co-payment but there is co-insurance.
-MAA-reimbursement here is to the member.

DRIECT ACCESS

3 TYPES TO ACCESS HN
HN CONNECT
GOOGLE.COM
Associate directory

arizone 31 oe_ 60
ca 30 - mother

Types of Plans:
1) CA, AZ POS (Point of Service)
*Tier 1, Tier 2, Tier 3

2) CA Elect Open Access
*Elect 1-HMO-Best feature with the flexibility of PPO
*Elect 2-PPO-Required PCP, Can go to different PPG.

3) CA EPO- Exclusive Provider Organization
*Tier 1 & Tier 2= No deductible but requires co-payment and co-insurance.

First Health-Network of Doctors
PPO plan- PPO travel access program.
CA available with PPO Plan only.
Access first the website to check if the doctor is affiliated
Arizona-

Medicare- Federal Health Insurance Program
*Age 65 and older
*Have permanent kidney failure (ESRD)
*Who are "totally" disabled.
-enrollment is handled by social security within exchange
contact Medicare on 1-800-MEDICARE
www.medicare.gov

4 Parts of Medicare

A- Hospital Insurance (Facility)
B- Medical Insurance (Doctors, Provider, Medicare professional
C- Medicare Advantage (Seniority Plus in HN
D- Prescription Drug Program (Pharmacy Coverage)

Medicare
Exchange
PPO

A- Hospital Insurance (Facility)-covers hospital and skilled Nursing Facility
-covers only 60 days of confinement & more than 60-> daily co-payment.
B- Medical Insurance (Doctors, Provider, Medicare professional)- includes rendered at home, have to met deductible before paying 20% of the co-insurance and co-payment. have to pay deductible to take advantage of the benefits, rbvbs pays 80%, member pay 20%.
C- Medicare Advantage (Seniority Plus in HN)- private sectors can contract with Gov't but have to met the private policies. automatic HMO
D- Prescription Drug Program (Pharmacy Coverage)- not covered by HN

ID


on exchange -