Eligibility
What documents are accepted for a newborn to be added to a policy?
Birth confirmation letter from hospital, (birth certificate or social security card can take weeks to be ready).
A member is calling in and their PTD is showing 01/31/2026 and is asking if they can pay $30 this week and the other $30 on Friday 05/05, what do you advise?
- After aptc their monthly premium is $20.00
They would have to pay the full balance by end of April to avoid termination.
A member is calling in to submit a appeal over the phone, what do you advise?
A appeal can not be received over the phone, they will have to complete the Member Appeal Form.
What system if used to submit changes for Off-Exchange members?
Admin Portal
A member enrolled in HMO went to a oon urgent care for a office visit due to their PCP being closed and is wanting to submit a claim for reimbursement, what do you advise?
Due to the member being enrolled into a HMO plan they would not be covered for oon services.
A GA member is calling in upset due to their deductible changing this month from what they originally enrolled into for Jan, what do you advise?
They have gone from 110025-05 to 110025-04
They would have to get with GAA, csr level is determined by income.
Where can you find the warning/termination letters sent to members?
Admin portal
What claim forms do we accept?
UB-04 and HCFA 1500
What 2 systems are used to track complaints submitted by members?
Callnotes and Meditrac
002- the wife is wanting to turn off the ach due to not having enough funds, what do you advise?
001 would have to call in and request for the ACH to be turned off.
AS9010000001 Is wanting to add her newborn to their coverage, what do you advise?
They would have to complete the solocare enrollment form, they have 60 days from DOB to add newborn.
This member has a monthly premium of $120/month and is showing in GP2 and is wondering why her provider is stating she is not active, what do you advise?
Member ID 441000025001
We would not be able to discuss any billing details with group member's and would have to refer them to their HR department.
What is the processing time for claims to be processed?
15-30 business days
In what system are we able to view how a member has set up ACH?
Harpo
What is the timely filing for a claim submission for a provider?
180 days from DOS unless contract states other wise
-002 member is having to enroll into a new policy due to 001 terminating the policy and is asking if their accums with roll over, what do you advise?
No if their member ID changes the accums will not roll over.
A member has had 2 service fee charges of $30 due to ach draft being returned due to nsf and wants to update their account information what do you advise?
With the member having 2 NSF returns they would not be eligible for ACH draft for 1 year.
What do our member id's start with and who do they belong to?
AM/44- Group
000- IFP
AS- IFP
In what system can we view why a payment has declined or print a copy of a receipt for a member?
Bluepay
A provider is calling in and is wanting to know if we received their appeal, what are your next steps?
What is the timely filing for appeals based on the DOS or Processed date?
Locate the claim and check under the events tab to identify if we have received the Appeal.
180- days from the processed date
A policy changing from On-Exchange to Off-Exchange, would the new policy have to be effectuated or will the member have a Grace Period since there will be no gap in coverage?
The new policy will have to be effectuated since it will be a new policy ID.
A member with APTC has a monthly premium of $20. The last payment made was $20.00 on 08/10/2025 and PTD is 08/30/2025. On 11/30 the member paid $50. It is now December 23rd and they want to pay the remainder due, what do you advise?
The full balance of $60 (September, October, November) was due by end of November to avoid cancellation; a partial payment would not bring them out of grace and has caused the policy to terminate back to 09/30/2025 9end of GP1).
If this member calls in wanting to set up ACH, what are you advising?
4410901547001 John Doe
They would not be able to set up ach due to being on a group coverage.
In what system can we print out a copy of a members deductible/out of pocket report?
Meditrac
What are 3 SEPs/QLEs that may qualify a member to be able to sign up for coverage outside of open enrollment?
- Birth
- Marriage
- Death of subscriber
- Loss of eligibility for Medicaid or CHIP
- Divorce
- Gaining status as a citizen/national or lawfully present individual
- Move outside of plan's service area