Communication Methods
What is a monthly, personal health finance and benefits statement that includes a member's medical and/or prescription drug claim information.
Medicare SmartSummary
What program will let members earn rewards by completing eligible activities that help them reach their health goals?
Go365
Does a prospective member have a Humana Member ID?
A prospective member is an unknown caller looking for Medicaid plan information such as benefit coverage or provider participation.
They do not have a Humana member ID and must be documented in CRM as an unknown member.
The physician is no longer a contracted network provider.
The member or provider moves.
The member is dissatisfied with their current doctor.
What is a repeat caller?
A repeat caller is a member who has contacted Humana within the last 14 days about the same issue without any resolution.
Primary.
Coordination of Benefits (COB) is a process used when a member has more than one insurance plan. The provider is able to bill both plans for services but one of the insurance plans is the primary plan and the other plan is secondary. COB ensures the combined payments do not exceed more than 100% of the total allowable.
What is the first page that opens when the member signs into to their account?
The MyHumana dashboard is the first page that opens when the member signs into to their account.
Please explain who is eligible for Medicare and who is eligible for Medicaid.
Medicare is for people 65 or older. Individuals may be able to get Medicare earlier if they have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also called Lou Gehrig’s disease).
Medicaid eligibility requirements vary by state. Eligibility is generally based on a person's income and assets in comparison to the Federal Poverty Level (FPL). The individual state determines a person's Medicaid eligibility.
Where are PCP changes made?
PCP changes are made via the PCP Update/Change template in CRM
True or False:
You are allowed to disconnect a call when the member requests to speak with someone else?
Do not disconnect any caller asking to escalate their issue to someone else. You are only allowed to disconnect calls when there is no caller on the line, or the call is a:
Robocall: computerized pre-recorded message
A fax machine (series of high-pitched beeps)
What form refers to written consent?
Written consent is indicated on a Consent for Release of Protected Health Information (PHI) form.
Common words associated with web related issues like browser, cache, cookies, URL, and encryption are related to what?
Troubleshooting
In what ways can a member request proof of coverage or information about their plan?
Members may request to receive proof of coverage or plan information in paper format vs. online. This could be a result of the member not having internet access, or simply their personal preference.
What type of complaint is a member’s expression of concern regarding the Quality of Care received?
A Quality, Attitude, or Access to Care (QAA), complaint is a member’s expression of concern regarding the Quality of Care received, the attitude of the provider, or a lack of access to desired or needed medical services.
What call type is seen as any derogatory or harmful language or behavior personally directed at you.
Abusive calls are any derogatory or harmful language or behavior personally directed at you. All advocates have the right not to be subjected to any abusive language or behavior including any of the following:
Statements are the same for all members because they are active members.
Statements are unique to each member. A husband and wife who both have Humana coverage would each receive a separate SmartSummary.
MyChart ____ time for treatment to our members.
MyChart expedites time for treatment to our members.
True or False:
ID cards are a common fulfillment request.
True.
ID cards are a common fulfillment request. There are times you may just need to view a card and assist members in accessing a copy of the card themselves.
PAAG is a back-end tool used to access more information about the provider’s credentials, demographics, or contract. What does PAAG stand for?
Provider at a Glance (PAAG)
Probing Questions.
Asking probing questions and conducting research will help you determine if you received the call in error or can assist them.
Member calls with questions about a letter they received. What would the Classification and Intent be?
Where can members locate forms via the Documents & Forms link?
Members can also locate forms via the Documents & Forms link under the Coverage menu.
When using ID Card Management link in the Plan Member page to submit a request for an ID Card, you could possibly see 4 different statuses. What are the 4 statuses?
When would you use Find Care?
The primary tool used to assist members with locating participating providers including PCPs is called Find Care. This online provider search application is used to search medical, dental, vision and pharmacy providers.
Test calls will be received occasionally. Where do they come from?
The Centers for Medicare & Medicaid Services (CMS) will occasionally make test calls (i.e., compliance calls) to see how long members wait on hold before they reach an advocate.
These calls are to test Humana, not you!