Payor Plan Soup
-
Upload
alexis-chen -
Category
Documents
-
view
34 -
download
5
description
Transcript of Payor Plan Soup
• Distinguish among the major types of plans, including HMO, PPO, EPO, and indemnity.
• Interpret the information provided on a patient’s insurance card.
• Select the correct payor plan.
Instructions• Click on the links in each session to advance.
Course Objectives and Instructions
START
What’s on a card?
Blue Cross/Blue ShieldDooble, Noodle Account NumberID Number 89676NOD129876
THE NOODLE COMPANYCOPAY: PCP SPEC ER
$10 $10 $40CUSTOMER SERVICE: (302) 437-0021
PPO
CLICK CROSS
Payor
Plan
What’s on a card?
CIGNA HMODUMPLINGS INC Group Number 123987ID Number: DUM89676
Dumpling, AppleCOPAY: PCP SPEC ER
$10 $25 $00CUSTOMER SERVICE: 1-800-437-0021
HMO
CLICK HMO
What’s on a card?
THE HERSHEY COMPANY
POSID W789 5324 GRP: 80734-768-72664
01 Mint, Cool 03 Mint, Curley02 Mint, Pop 04 Mint, ChocolateCOPAY: PCP SPEC ER
$20 $20 $00CUSTOMER SERVICE: 1 (800) 435-7266
AETNA
CLICK POS
Plan Type: PPO Plans
• Preferred Provider Organization
• Part of a “network”
• If a network provider is used, an adjustment or discount is taken
• If a out of network provider is used, out-of-pocket cost is higher
CLICK ORGANIZATION
• The entity that pays the claim
• Examples:– Aetna– Blue Cross– Cigna– Medicaid– Unision
What is a Payor?
1. CLICK Aetna – Review - CLICK “X” to close website
2. CLICK Cigna – Review - CLICK “X” to close website
CLICK HERE TO CONTINUE
Plan Type: POS
• Point Of Service• Treated as an HMO plan, but also has
out-of-network benefits• Patients have a Primary Care Physician (PCP)
or “gatekeeper” who manages their healthcare• Patients are typically subject to a deductible and
out-of-pocket costs if PCP does not authorize visit
• Authorizations are required for maximum benefits
CLICK HMO
Plan Type: HMO
• Health Maintenance Organization
• Also known as “managed care” plans
• Patients have a Primary Care Physician (PCP) or “gatekeeper” who manages their healthcare
• Co-Payment due at time of service
• Referrals and authorizations are required
CLICK GATEKEEPER
Plan Types: EPO
• Exclusive Provider Organization
• Some plans are treated as HMO and require authorization
• Other plans are treated as PPO and do not require authorization, but have no out-of-network benefits
• Very important that information is verified before patient is seen
CLICK HERE
Let’s Review
• COB is for Coordination of Benefits, not a Plan Type, try again.
RUL POS COB EOB
CLICK HERE
Select the Plan Type
Blue Cross/Blue ShieldBean, Kidney Account NumberID Number 89676SNI129876
SNICKER VALLEY SCHOOL DISTRICTCOPAY: PCP SPEC ER
$15 $25 $40CUSTOMER SERVICE: (800) 437-0021
EPO
CLICK EPO
Let’s Review
• What is a Plan Type?
B. A Product Line – Correct
Every payor has multiple product lines.
CLICK PLAN TYPE
Which Plan requires a Primary Care Provider
CONGRATULATIONS – YOU ARE CORRECT!
HMO requires that you select a Primary Care Provider to be your “gatekeeper”
CLICK HERE