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what's the other name for a redetermination?
Medicare Part D prescription drug appeals
The first decision made by Humana regarding payment or benefits a member believes they are entitled to.
What do HCPR determinations include?
What is a DMR claim?
A coverage determination that is also made when manually processing a paper claim submitted for reimbursement of out-of-pocket expenses.
What are the types of coverage determination?
When does a pre-service determination apply?
Applies to medications requiring prior authorization from HCPR.
What does a coverage determination include?
Includes tier, drug list, or quantity limit exceptions requiring HCPR review.
A member calls to recover an OOP cost: on what category of determination would this fall under?
Reimbursement
What are the two outcomes for a determination?
Favorable and Adverse decision.
How can a re-determination form be submitted?
Through mail, verbally, or online by www.humana.com
Carlos is upset upon learning the closest participating pharmacy is over 30 miles from his home. Tell the type of complaint.
Grievance
What's the difference between a determination and a re-determination?
A re-determination is filed when a prior authorization request has been denied by HCPR.
An appeal that warrants immediate attention when waiting for the standard appeal timeframe could negatively impact the member's health.
When the standard timeframes could:
What's the timeframe that HCPR has to callback for an appeal?
What details does a member need to leave when HCPR is out of business hours?
True or false: A tier exception is a re-determination.
False
What does a member must mail to Humana when seeking a reimbursement?
What are the parts of a "Part D Evidence of Coverage Booklet Appeal Form"
Member rights, redetermination definition, and part D appeal form.
What tool must you use to send a re-determination form through Mail?
OMS
On what mentor can you find the code for a Re-Determination Form on OMS?
OMS OES Codes Index
what are the five levels for appeal on Part D?
Redetermination, reconsideration, ALJ hearing, MAC Review, Judicial Review
what mentor contains the steps to manage a redetermination call?
Medicare Medication Redetermination Calls
what mentor talks about HCPR in detail?
HCPR Department Overview
What is the EMME code for the re-determination form on english?
GHHH7A1HHA