IFM II: Pulling Preventive Benefits

Every time we quote members’ benefits, we use Benefit Navigator because it gives us the​ (a)   and ​ (b)   so we can provide correct benefits.

• keyword
• Service
• Provider
• in-network
• out-of-network

Answer explanation

We use the keyword and Service ID to pull the correct benefits in RTB. We also use Benefit Navigator because it provides tips for quoting benefits and other information that the member needs to know.

When taking actual calls and using live ACE, we launch Benefit Navigator from ​ (a)   and not from ​ (b)   .

• ACE Quick Links
• Automation Team App
• Links A-Z

Answer explanation

Accessing Benefit Navigator/RTB from ACE Quick Links, automatically opens the member’s account in Benefit Navigator, avoiding the need search for and enter the Group and Subscriber numbers. This also allows Streamline RTB to create a CASE with the benefit quote.

To determine which ​ (a)   to quote, we need to ask ​ (b)   questions.

• service
• probing
• yes/no
• member
• complicated

Answer explanation

To determine which service to quote, we need to ask probing questions such as: Who is receiving the service? What service does the member need? Who will perform the service? Where will the service be performed?

When quoting ​ (a)   , we always need to advise our members that it is of the allowed amount.

• coinsurance amounts
• in-netword
• in-network amounts
• out-of-network amounts
• used and remaining amounts

Answer explanation

We should always advise our members that the coinsurance is of the allowed amount because this is the maximum amount that we will reimburse the providers for a service. Providers, at times, charge more than the allowed amount. The member may or may not be responsible for any amount over the allowed amount depending on the network status of the provider.

Which provider category should we select if a member is receiving services at an imaging center?

• Professional

• Institutional

• hospital

• facility

Answer explanation

Imaging centers are considered Professional providers. We can find this information in the ProcedureFlow Document: Code - Provider Type Blue Shield.

When a service is performed at the PCP’s office, what do we typically select when answering the Benefit Navigator question "What is the place of treatment?".

• Office

• Independent Laboratory

• Outpatient

• In patient

Answer explanation

If you are not sure which place of treatment to quote, run benefits for both office and outpatient.