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Payor Plan Soup

Payor Plan Soup. Jackie Ruley EDT6000 January 18, 2010. Course Objectives and Instructions. 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

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Payor Plan Soup

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  1. Payor Plan Soup Jackie Ruley EDT6000 January 18, 2010

  2. Course Objectives and Instructions • 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. START

  3. Let’s get Started CLICK HERE CLICK HERE

  4. PLANS MANAGED CARE Open Access QPOS EPO PPO POS OA HMO Click PPO

  5. What’s on a card? Payor Plan Blue Cross/Blue Shield Dooble, Noodle Account Number ID Number 89676 NOD129876 THE NOODLE COMPANY COPAY: PCP SPEC ER $10 $10 $40 CUSTOMER SERVICE: (302) 437-0021 PPO CLICK CROSS

  6. What’s on a card? CIGNA HMO DUMPLINGS INC Group Number 123987 ID Number: DUM89676 Dumpling, Apple COPAY: PCP SPEC ER $10 $25 $00 CUSTOMER SERVICE: 1-800-437-0021 HMO CLICK HMO

  7. What’s on a card? THE HERSHEY COMPANY POS ID W789 5324 GRP: 80734-768-72664 01 Mint, Cool 03 Mint, Curley 02 Mint, Pop 04 Mint, Chocolate COPAY: PCP SPEC ER $20 $20 $00 CUSTOMER SERVICE: 1 (800) 435-7266 AETNA CLICK POS

  8. 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

  9. What is a Payor? • The entity that pays the claim • Examples: • Aetna • Blue Cross • Cigna • Medicaid • Unision • CLICK Aetna – Review- CLICK “X” to close website • CLICK Cigna – Review - CLICK “X” to close website CLICK HERE TO CONTINUE

  10. The product lineoffered by the Payor What is a Plan?

  11. Plan Type: PPO Plans Preferred Provider Organization CLICK PPO

  12. Plan Type: HMO Health Maintenance Organization CLICK HMO

  13. Coverage Definition The patient’s insurer, which consists of apayorand aplan. Click on payor

  14. 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

  15. 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

  16. Plan Types: EPO Exclusive Provider Organization CLICK EPO

  17. 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

  18. Which Plan requires a Primary Care Provider THPOAHMO

  19. Every Payor needs a Plan? CLICK PLAN

  20. Let’s Review • COB is for Coordination of Benefits, not a Plan Type, try again. RUL POS COB EOB CLICK HERE

  21. Select the Plan Type Blue Cross/Blue Shield Bean, Kidney Account Number ID Number 89676 SNI129876 SNICKER VALLEY SCHOOL DISTRICT COPAY: PCP SPEC ER $15 $25 $40 CUSTOMER SERVICE: (800) 437-0021 EPO CLICK EPO

  22. Let’s Review • What is a Plan Type? A. A Model B. A Product Line C. A TV Show

  23. Let’s Review • What is a Plan Type? C. A TV Show – Sorry Try Again CLICK HERE

  24. Let’s Review • What is a Plan Type? B. A Product Line – Correct Every payor has multiple product lines. CLICK PLAN TYPE

  25. Let’s Review • What is a Plan Type? A. A Model – WRONG Try Again CLICK TRY AGAIN

  26. Let’s Review • Select a Plan Type. RULPOSCOBEOB

  27. Let’s Review • EOB is an explanation of benefits. Select again. RUL POS COB EOB CLICK HERE

  28. Which Plan requires a Primary Care Provider THP – IS TOTAL HEALTH PLUS SORRY CLICK HERE

  29. Which Plan requires a Primary Care Provider OA - IS OPEN ACCESS TRY AGAIN CLICK HERE

  30. 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

  31. Theend Jackie Ruley EDT 6000 January 18, 2010 CLICK THE END

  32. Let’s Review • Sorry Wrong Answer – TRY AGAIN RUL POS COB EOB CLICK HERE

  33. Let’s Review • Select a Plan Type. RUL POS COB EOB Yes, a POS is a Point of Service Plan. It is treated as an HMO plan, but also has out-of-network benefits. CLICK HERE CLICK POS

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