HIPPA
What caller type is a Tier2 Navigator calling us Tier 1 advocates? What information do we verify for the member and the caller?
Internal Caller -- member name + one piece of identification + callers name + their dept. -- verify caller via Sparq/Outlook/Teams
How do I send an ANOC?
Member Materials Intent in Maestro
Name the Category and Subcategory that a member expressing dissatisfaction due to: never having received their ID Card (not requested before this call)
Plan >> ID Card Not Received
QI, QWDI, and SLMB (only)
The system that houses previously submitted coverage determinations for Part D benefits
PAS - Prior Authorization System
Can an Authorized Representative file a grievance on the members behalf without their permission?
QOC, yes. Standard, no.
Where can you view the details of previous advocates interactions with the member?
Recent Interactions in Maestro
Name the Category and Subcategory that a member expressing dissatisfaction due to: not having received their ID Card (HAS been requested prior to this call)
Call Center >> Advocate Interaction
There are no claims on file for the date/event the member is receiving a bill for. What is a good probing questions you would ask your member.
Did you present your insurance card(s) to the provider?
The system that houses previously submitted member initiated organization determinations (MIODs) for Part C Benefits?
Use member ID: 122034996 and share your screen. Please show us how you would verify any callers BEFORE you enter the members account. How do we continue/add one time caller details for somebody that is not listed?
Do not click on the Caller is the member -- Create Quick Contact
If a member wants to schedule a Housecalls Visit -- do we transfer this call? And if so, please provide the Department Name and Phone Number
Housecalls Dept. 866-686-2504 -- Found in KM1006693
If the member is expressing a dissatisfaction with their Provider/Prescriber (not spending enough time with them) and they said the Driver was rude when they were taken to their appointment. Is this ONE or TWO Grievances? If there are two, should they be filed TOGETHER or SEPARATE
Two -- Separate
$0
The system where Members Medicaid MCO can be found
DMEVS
Name and DOB + permission to speak on specific topics. Yes, we should ask them. Add Auxiliary persons intent
Update Member Profile >> member Preferences >> select "No" to Sending Promotions via phone and via mail
If the member missed three appointments on 10/10, 10/5, and 09/28, due to transportation not showing. Is this ONE or TWO Grievances. If it is two, should they be filed TOGETHER or SEPARATE?
One - Together
Medicare and Medicaid (DSNP Members)
System where OTC Benefit Balance and Replacement Benefit Cards can be sent from
Solutran PSP Portal
If the member is deceased and their Legal Designated Person is calling, can we discuss the members Medical Information?
Yes
How many phone numbers can a member have listed? What are they?
Three -- home, mobile, alternative.
I am need to go to a doctors appointment in Columbus, Ohio (I am on plan H5253-059 -000/ is aligned) but I live in Akron, Ohio (zip code 44312/not a veteran). Is that covered? If not, what can I do? I need to get to that appt. and I don't have a car.
Advise member of benefit limit for mileage, advise member of local recourses, IF the member still pushes back suggest MIOD with honest expectations
If the member is getting a bill AFTER Medicare and Medicaid has paid (Balance Billing), what is the SOP we use that PROVIDES SCRIPTS of what to do/say when speaking the provider?
Claim Inquiries - Educating Provider on Balance Billing Issues - Tier 1
Two possible answers (based on the two states we service). System used to locate INN Routine Vision Providers
UHC Vision Website and MarchVision Website