JAA Quick Test

We use the Employer Contract Number when checking JAA information

• True

• False

Caller says they are INN. I should

• Take their word for it

• Check CA Mainframe

• Check Findcare

• Check Network Information

As this is a self-funded policy, we are not granted the permission from the employer group to inquire about member requested materials, such as accident reports, COB updates, etc. as this is between the member and member services.

 

Once the member has returned the requested information, the employer group will adjust affected claims. If claims have not yet been adjusted, the member will need to communicate this to their member services.

When do we say this?

• When asking for COB

• When asking for Eligibility

• When asking for Accumulations

• If group is Wellpath

These amounts may change through processing of new claims or adjustment of previously processed claims.

We say this when quoting

• Benefit Information

• Coordination of Benefits

• Precertification

• Accumulations

We use the following when checking Benefit Information...

• NLS

• NLS - Legacy

• FOBS

• EOC

• NIC JAA

These are the things I need to provide when quoting Eligibility

• Policy Status

• Effective Date

• Benefit Period

• Contract Type

What do we do when the group is on Do Not Call?

• Refer to VRU

• Refer to OE/SME

• PACB

• Call any number in the Update page

What are the things we need to have when checking JAA In Scope Indicators?

• Update Pages

• UM Profile Pages

• Workflows

• JAA WGS Master List

What does this tell you?

• AIM is purchased and may be referred to CMBM

• Precertification is being handled via their TPA

• Precertification is handled by UM

• AIM is not purchased, and needs to reserch further.

If claim is past the Claims Run-out Date, I should...

• Send the claim back to the TPA

• Refer the caller to their local

• Refer the caller to coordinate with member