Common Audit Opportunities
During what months of the year does a CN ask the member for the Flu shot?
What is September to April?
What must we do on every 3rd party call?
What is advise the call is being recorded?
If we are calling the Authorized Representative on a quarterly outreach, what must we do first?
What is make sure the Authorized Representative is still listed with Member Services or validated in I-CUE?
I won $10,000 on a scratch ticket when I was 16 but couldn’t cash it since I was not old enough to buy.
Who is Melissa Kosmowski?
What can we use to check member’s plan benefits?
If a member's sub-status is DNC, how many times do we reach out for a Nurse Line follow up task? How many times if the member's sub status is UTRed/Loss of Contact?
What is
If DNC, we do NOT reach out
If UTRed/Loss of Contact, one attempt only?
If you have provided a member a specific specialist name and number, what option would you select in PW under "referrals made"?
What is General?
If the member initially declined a FTF visit but agrees to a quarterly telephonic contact, what is the proper sub status to select?
I went vegan for two years?
Who is Jeremy King?
What is the system used to obtain information such as Medicaid provider, Medicaid Level, Medicaid ID, and member demographics?
What is DMEVS?
What two outreaches do we confirm the name of the member's PCP and offer to schedule a follow up appointment with the PCP?
What is
the initial call and every 90 day follow up?
If you provide food, utility, and lawn maintenance resources, what do we select for the referrals made?
What is food, utility, and general?
If a facility/provider call us back, what is the correct information to verify?
What is
-the name and address of the provider/facility
- authenticate ALL 3 of the HIPAA elements as you would if they were the member?
I have an identical twin sister, but I am older by one whole minute!
Who is Naomi Ortiz?
What is the name of the website we are to use to assist the member to find an chiropractor or acupuncture to utilize their ROUTINE benefit?
What is MYOPTUMHEALTHPHYSICALHEALTH.COM?
If you make a successful call to a UTRed member that is "stable," would their risk level change? if so, what would it be changed to?
What is the risk level is changed back to the most recent risk level done by the predictive model?
If a 3rd party tells us the member is not interested in the OAH program, what is the appropriate disposition to select for the "Outcome?'
What is DNC?
What are the 4 reasons for a case closure?
What is
-MEMBER DECEASED
-LOSS OF ELIGIBLITY
-OPT OUT
-HOSPICE MEMBER
I had the opportunity to fly a plane on my own for a few minutes!
Who is Marcela Varela?
What is an alternative system to I-CUE that can be used to see what pharmacy the member might be using? It also can be used for utilization/health history?
What is IHR?
What are the 5 main things the CN says to the member before ending the call?
What is
1. provide/offer callback number & extension
2. provide/offer Nurse line and MS (on the back of the card)
3. ask for any questions from the member
4. summarize key details of call
5. let the member know the timeframe/date of the next call and next steps?
If a member is dissatisfied with Modivcare, who do send an email to and what must be included?
What is
-qualityassurance@modivcare.com and CC: christine_armijo@uhc.com
-Member’s name
-Member’s ID
-State abbreviation
-Date of birth
-Effective date
-Contract and PBP Numbers
-Date of Service Reason for complaint?
What are the 7 star gaps that do not require action from a CN?
-ABA/BMI
-ART
-CDCNEPH
-HRM
-FMC
-MRP
-PCR
I went to school to be a paramedic.
Who is Karla Arana?
What are the 4 requirements to report emotional/physical abuse and what is the timeframe?
What is
1. Submit to the Complaints & Compliments Issue Mgmt SP
2. Call the local abuse hotline
3. Document Safety Concerns as Outcome in PW
4. make sure to document the Ticket Number for future reference
SUBMIT WITHIN 24 HOURS OF RECEIPT OR IDENTIFICATION (WHENEVER POSSIBLE