IFP
You are working on an IFP member's claims appeal, but you are needing more information from the provider and the timeline is coming due- are you able to take a 14 day extension to try and obtain this additional info? (Yes or No)
What is No
A Medicaid member filed a grievance based on a conversation that had with their UCare care coordinator. Is A&G able to accept this as an grievance? (Yes or No)
What is Yes
A Medicare member files an oral grievance with our Customer Services department. What is the timeline for A&G to complete this?
How long are Power of Attorney (POA) papers valid?
What is C.-Never expires as long as the member is alive
You are working a service appeal and know that the workflow process states you need to contact the provider to ask if they have additional information. How many attempts need to be made?
What is A. 3
An IFP member just called in and filed an appeal for the denial of their Omeprazole medication. You look and see this medication is not on the member's formulary. How many hours do you have to complete this appeal?
A provider appeals on behalf of a Medicaid member's medication denial and we upheld the original decision. The provider would like to do a peer to peer review, but you notice AMR conducted the review. What do you do next?
A Medicare member files an appeal on claims denial they received in Sept 2019. After seeing this, what do you do?
If there is an MSHO member that sent in an appeal for Elderly waiver services, which benefit do we process his appeal under.
We receive an oral grievance that Customer Service set-up, but the member was not advised of their additional rights. What do you do next?
An IFP member's appeal was upheld and they are wanting to know their second level appeal rights.
What is Minnesota Department of Health or Department of Commerce
Which Rights are given to Medicaid members upon giving them their resolution on an oral grievance?
What is A. The Right to a written grievance Ombudsperson and MDH contact info
A Medicare member's appeal is upheld, and they are wanting to know their second level appeal rights?
What is Maximus
You are working a claims appeal and see that the member is appealing their $300 bill they received due to their in-network provider sending their lab tests to an out of network provider. Who is able to make the business decision for this appeal?
What is B. Use the Business Decision Making Grid
If the intake screen states 1/1/23, but the appeal letter states 1/2/23. What do you do?
A. Change to correct date and add a 'Date Modified' note
A contracted provider for an IFP member is filing a claims appeal, but we see that we do not have the member's written consent for the provider to file on their behalf. What do we do next?
Do the Aspirus plans have their own materials? Yes or No?
What is Yes
A&G receives a claims appeal from a non-contracted provider who is appealing the allowed amount. Can we accept this appeal? (Yes or No)
What is No (This would be sent to our Claims Dept)
19.A member that has D-SNP has their spouse filing on their behalf. Which type of authorization can be used for their spouse to appeal on their behalf?
What is B.-CMS-1696
If a member receives emergency services at a non-network emergency department, can they be balance billed?
A Medicaid pharmacy appeal is received during the on-call weekend. The case is resolved, but you can’t get ahold of the member. What do you do?
B. Mail the letter to the member
When is an SNF appeal considered urgent?
What is C. Upon receipt if less than 12 hours from discharge
If you are assigned to be intake back-up for the day, what do you do?
What is C. Watch your group chat for updates from the intake specialist
If you receive an appeal in which the DTR is dated in 2022, but the appeal was initiated in 2023, which coverage criteria plan year do you reference?