Resolution
What is the estimated time of arrival for new members' ID cards?
2-3 weeks. SOT: KM1974304 Member Materials - Replacement ID Card Requests in Maestro
What actions should the advocate take when addressing a grievance that necessitates a transfer during the call?
If a transfer is required, document completely before transferring the call to another department.
Where can we locate the appeal status in Maestro?
A&G Cases Tab
What would the advocate do if the member is calling for the same issue with a 'Resolved-Completed' grievance status?
Use the CAG intent to document a new grievance. SOT: KM1005774 Grievance Handling (Medicare and DSNP) - Complaints Appeals and Grievances
What do you call the complaints occur when services received by a member from a medical provider / facility or pharmacy are inadequate or substandard in quality.
Quality of Care
Apart from searching the 'Review Medical Benefits' intent, what other resources can the advocate utilize to identify the right transportation vendor?
Utilize KM1770150 Wellness Benefits - Transportation - Determining Transportation Vendor.
What should you do if a member presents multiple grievances during a single call?
It is required to create separate intents if the grievance falls under multiple dropdowns. Select Yes to Do you have any other issue to capture all complaints presented on the call.
What is the turnaround time for the Expedited Appeal for Part D drugs?
Part D: 72 Hours
What article can the advocate use if member would like to file a complaint regarding privacy policies and procedures?
KM1005783 HIPAA - Privacy Complaint.
Member experienced a delay in receiving medication(s) due to pharmacy's action, and the member ran out of medication(s)
Quality of Care
Where can the advocate find out the member's limitations on the frequency of dental cleanings?
Go to KM1192952 Dental Provider QRG.
How many intents the advocate must open if the member has multiple issues with transportation?
1 intent only, This includes multiple Transportation issues with several appointment dates.
What do you call the appeals of a service that requires notification or approval prior to receiving medical care?
Pre-Service Appeal
What is the source that the advocate should pull up if the caller is the member's attorney filing a complaint?
KM1006151 Situational Guidelines - Escalated Caller - Advocate Responsibilities.
Member experienced a delay in receiving medication(s), pharmacy out of stock due to manufacturer issues
Quality of Service (Standard Grievance)
Who would cover all the hospice services received by VBID members on or after 01/01/2025?
Original Medicare SOT: KM1004519 Benefit Inquiries - Hospice.
An authorized representative (AR) of the account wishes to report a previous representative's rude behavior towards the member. What initial steps should be taken before submitting a verbal grievance report?
Obtain a verbal consent first from the member
What is a post-service appeal?
The appeals for a medical service that has already been rendered. In other words, the service was provided and, having been denied for payment, the member or provider is asking for the review of the denied claim.
Where can the member submit their written complaint for the alleged discrimination experienced from their provider's office?
UnitedHealthcare Civil Rights Coordinator SOT: KM1005117
Member dismissed from provider's practice and unable to access care with another provider
Quality of Care
This is called a 'decision tree' where advocates are guided to be able to provide the complete quotation of the member's benefits.
DT1014613 - Quoting Benefits.
This type of verbal grievance includes all interactions where the advocate shows rude behavior, provides misinformation, excessive transfers, Issues left unresolved, not being assisted.
Verbal grievance - Customer service.
What do you call when an Organization Determination may be denied, and a provider is able to call in to speak with a Medical Director?
Peer to Peer Review
For OptumRx Complaints, what would the advocate do if there is an additional follow up action needed?
Refer to KM1006047 Submitting a CSRF>Advocate Action.
Member dissatisfied with treatment plan or care received, or is misdiagnosed by a provider
Quality of Care