HIPAA
Please provide three forms of HIPAA that we are able to validate
Name, DOB, Health Plan ID#, Medi-cal ID#, Physical Address, Mailing Address, Last four of SSN#
Who manages dental benefits?
Medi-cal Dental
What color is the flag when member is active with Health Plan?
Green
What does Health Care Options do?
Helps educate, enroll and disenroll from managed care plans
Where are members able to get their vaccines/immunizations from? (Child and Adult)
Child- PCP
Adult- PCP or Pharmacy
Caregiver affidavit
Who coordinates Vision Benefits?
VSP
What color is the flag on qnxt if member is termed with the health plan?
Red
Validate mailing address and ensure that one has not been sent within the last 14 days
Provide examples of providers that member does not need a referral to see
PCP, Chiropractor, OBGYN's, Podiatrist
Form to add an authorized rep
AUTHORIZATION FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION
Western Drug
What color is the flag if member has another insurance and health plan is secondary?
Yellow
How long does a member have to send us a termination letter?
5 business days
What are the requirements for COC (Continuity of Care Requests)?
Provider is out of network and member has accessed care within the last twelve months
Where is the members rate group found in qnxt?
Eligibility>Miscellaneous Tab
Who covers glucose monitors?
Medi-cal rx
What do we advise if member is requesting to know why they were disenrolled from health plan?
Contact your caseworker
If a member states they are not able to get another medication due to another insurance, what system are they referring to?
Medi-Cal's (AEVS)
If a member wants a second opinion, what must they do?
Obtain a referral from PCP or specialist they are currently seeing
REQUEST FOR AN ACCOUNTING OF DISCLOSURES
If a member is requesting provider options for a therapist, who is able to get them those options?
Customer Service
When a member states that they wish to disenroll from the health plan, who must they contact?
Health Care Options
Plan B
Behavioral health services
• Belly binding after cesarean section by clinical personnel
• Clinical case coordination
• Health care services related to pregnancy, birth, and the postpartum period
• Childbirth education group classes
Comprehensive health education, including orientation, assessment, and planning (Comprehensive Perinatal Services Program services)
• Hypnotherapy (non-specialty mental health service)
• Lactation consulting, group classes, and supplies
• Nutrition services (assessment, counseling, and development of care plan)
• Transportation
• Medically appropriate Community Supports services