Benefits
What is the PERS and how can we assist the member in getting set up with this benefit?
Personal Emergency Response System (life alert)
We can reach out to Lifeline to assist in getting the member set up.
What are some examples of probing questions that you would ask for a claims inquiry?
What is LIS and what will the copays be for each level in 2024?
Low Income Subsidy. Levels are as follows:
LIS 1 - $4.50 for generic and $11.20 for brand
LIS 2 - $1.55 for generic and $4.60 for brand
LIS 3 - $0 for both
Which intent would you use to find out whether or not a member's drug is covered?
Formulary intent
Which states have been impacted by cost share programs?
AL, FL, and TX
A member calls in to get a shower chair. Is this covered and how can they get one?
Shower chairs are not considered to be DME, but if your member has the OTC benefit they are included in the catalog! You can reach out to Solutran to assist a member in ordering one.
You need to resend an EOB for the month of October 2023 per your member's request. How could you do so?
By following the process in Doc360, KM1555006
Your member calls and wants to get set up with home delivery for their medications. How can we do this?
By contacting OptumRx Home Delivery!
What should the structure of every call include? Give an example of call flow
Opening/branding, HIPAA verification, AWE statement, recap, offer of additional assistance, closing/branding.
What does an aligned member need to show at the time of their appointment? How about an unaligned member?
An aligned member will need to bring only their UCard at the time of the appointment. Unaligned members need to bring both their UCard and Medicaid ID.
A member recently tried to get their Continuous Glucose Monitor (CGM) at the pharmacy, but they were told that they'd have to pay a copay which they don't normally have to do. Why is this?
If we look at KM1005549, we can see that a CGM is considered to be DME, not Rx. This should have been sent to a DME vendor instead of the pharmacy.
Your member is delegated through WellMed and has a concern about a prior auth for an x-ray that was recently submitted. How would you assist this member?
For prior authorizations or claims related to WellMed delegated members, we would actually reach out to EviCore.
What is the process to get an override for a lost or stolen medication?
First and foremost, there will need to be a denied claim for this prescription with today's date of service. If you've confirmed in the Rx claims intent that there is, you can proceed to contact OptumRx Help Desk and request an override. After this, you can reach back out to the pharmacy, have them run the claim again, and it should process.
You answer a call and the member is very upset about an issue with a claim where their Medicaid was not properly billed in GA. What are some examples of things you could say to de-escalate this situation?
"I certainly know how frustrating a situation like this can be, but I want you to know that I've seen this issue before and I'm confident that I can get you a resolution."
How long does it take for the Medicaid portion of a claim to be processed and paid with aligned members?
Up to 60 days
Your member calls in to order a Fitbit through their plan, and you've verified that they are eligible for one. How do we order them?
Follow the steps in KM1028959 for how to order
You have a member on the line (they live in GA) who has received a bill from their specialist for a copay of $70. They have QMB Medicaid. You call the provider's office and they do not accept Medicaid. What can we do?
Members with QMB status Medicaid (QMB Only AND QMB+) it is actually both illegal and a breach of the provider's contract to bill these members. If you call and advise the doctor's office of this, they're generally very understanding and just didn't know the member has QMB status.
Your member just recently signed up for the plan and they're trying to get their prescription for Tramadol covered, but they're being told by the pharmacy that they can only get a 7-day supply. Give an example of the verbiage you could use to explain why this is happening.
"So because this is considered a controlled substance, we have to limit your first time getting this prescription. Now after the 7-days, you can go ahead and get that typical 30-day supply, it's just like a trial run. This isn't UHC's policy, it's actually part of federal law that we are required to adhere to."
You get a call from Solutran who needs to transfer a member over to find out if they're going to have to pay cost-sharing for a visit to the ER. They have a $90 copay per review medical benefits and their level of Medicaid is SLMB - they live in Colorado. How would you handle this call?
It's important to remember that Solutran cannot HIPAA verify a member! You have to get full verification from the member directly. SLMB members are responsible for their copays, but we can check findhelp.org for resources.
With the cost share programs: what should we tell a provider if it has been more than 60 days since the Medicare portion of their claim has been paid, but they still haven't received any cost sharing for the Medicaid portion?
In KM1007236, if you look under the tab "claims issue resolution & escalation M&R," you'll find your answer under step 4
A member got a pair of dentures in 2021 through UHC, and last week they lost them. What process could we follow to try and get the member another set of dentures, and what are some probing questions we might ask the member?
Previously you would need to file an MIOD, but these calls can now be escalated to the specialized dentures team.
Your member went to see their PCP two times recently: once in October and again in November. In October they had a copay for the office visit of $20, but in November they didn't have to pay anything. What could be the issue?
If something changed from month to month, the first thing you would want to look at is their Medicaid level. Did something happen with the member's income that would have caused them to go from a non-cost sharing level to a cost sharing level?
A member is new to the plan and trying to fill their prescription (don't get hung up on the kind of medication y'all) but they're being told that it's not included in our formulary. They have already tried alternatives prior to joining UHC and the brand name is the only drug that works for them. What process can we follow to try and get this covered?
This process would be a coverage determination, and we could do a transitional refill while waiting for the CD to process. It's important to note that OptumRx is now processing CDs, but when you reach out to them to initiate please call it a prior authorization.
Your member recently received a call asking if they'd like to receive an in-home vision screening since they're diabetic and they're trying to learn more about it. What can this member expect?
Explain Alabama's "lesser-of" logic
A state with a lesser-of policy would compare the requested Medicare cost sharing to the difference between the state's Medicaid rate and the Medicare payment amount and ultimately pay the lesser amount. In instances when Medicare has already paid more than the Medicaid rate for a particular service, under a lesser-of policy, the Medicaid responsibility has been met and no additional payments will be made to the provider.