Golf
1) When receiving a CMS Test Call, what are the correct Classification and Intent selections?
a) Other & Test Call
b) Misrouted Call & Transferred to Correct Skill
c) Benefits & Verification
d) G&A & Status
a) Other & Test Call
When updating a Primary Care Physician (PCP), and the member has a specific provider
in mind, what do you do?
a) Check the provider’s availability in the Find Care tool.
b) Check the provider’s availability by performing a Physician Search within the
PCP Change Template.
c) Contact the provider’s office to determine their availability.
d) Check Humana’s provider list to determine the doctor’s availability.
Check the provider’s availability by performing a Physician Search within the
PCP Change Template.
Which of the following is NOT considered a Medicare covered dental service?
a) Fracture of the jaw or facial bones
b) Routine extractions
c) Extraction of teeth to prepare for radiation treatment of neoplastic cancer diseases
d) Setting fractures of the jaw
b) Routine extractions
How do you handle calls regarding members asking about Gastric Bypass surgery for
weight loss?
a) Refer to the outpatient benefits and authorization requirements
b) Ensure that the operating physician is in-network
c) Advise that another area will assist them and transfer the caller to CIT to get the
authorization initiated
d) Advise that another area will assist them and transfer the caller to a dedicated
associate for bariatric calls
d) Advise that another area will assist them and transfer the caller to a dedicated
associate for bariatric calls
A member with an EyeMed Vision plan is calling regarding upcoming cataract surgery.
How do you handle this call?
a) Transfer the member to EyeMed and provide the member with the number
b) Provide the member with their surgery benefits via DEBUT
c) Advise the member that optical surgery is not covered under Medicare
b) Provide the member with their surgery benefits via DEBUT
What is the first course of action taken if you receive a phone call that's threatening
Humana? a) Inform the member you will be disconnecting the call and then hang up
b) Note as much information as possible and verbally notify leadership
c) Mute your phone and tell your neighbor
d) Hold an aggressive tone with the member
b) Note as much information as possible and verbally notify leadership.
A new ID card is automatically issued anytime a PCP is updated for members with
which plan type?
a) HMO
b) PPO
c) LPPO
d) PDP
a) HMO
Which of the following is NOT an example of Durable Medical Equipment (DME)?
a) Wheelchair
b) Catheter
c) CPAP Machine
d) Walker
b) Catheter
Which part of Medicare is a glucose meter covered under?
a) The member's Part D Prescription Drug plan
b) The member's Part B DME Medical benefit
c) It is not covered by Medicare
b) The member's Part B DME Medical benefit
Which of the following statements is true with regard to medical supplies?
a) Supplies are able to withstand repeated use
b) Supplies can only be purchased to treat a medical condition
c) Supplies require a prescription or certificate of medical necessity
d) Supplies are disposable
d) Supplies are disposable
How do you schedule time to place an outbound return call to a member when
needed?
a) Set a time with member and make a note for yourself to call them back
b) Create a CRM Notification Task and route it based on Mentor’s guidance
c) Send an email to your supervisor and leave the case open until you hear back from
them
d) Close the case and forget about it
b) Create a CRM Notification Task and route it based on Mentor’s guidance
When a hospital is in-network (INN) for a member’s plan, what does this mean for the
physicians that practice at that location?
a) All physicians are in-network (INN) as well
b) None of the physicians are in-network (INN)
c) A separate physician search must occur to confirm
c) A separate physician search must occur to confirm
Which of these Part B plans require accessing the referral guidance tool to verify if a
referral is required?
a) MEP (PPO) only
b) MEP (PPO) and MER (HMO)
c) MRO (HMO-POS) only
d) MER (HMO) and MRO (HMO-POS)
d) MER (HMO) and MRO (HMO-POS)
) A member is reporting an out-of-state address change effective immediately but also
wants benefit information for a surgery that will occur in a few months.
How do you handle this?
a) Update the address and provide benefits based on the information in DEBUT.
b) Advise them we’ll wait to update their address until after the surgery as their plan
will change and it could interfere with the planned surgery.
c) Update the address and connect them to sales for a plan update in their new
state at which time, we can provide benefit information under their new plan.
d) Update the address and advise the member to call back at a later time for plan
information.
c) Update the address and connect them to sales for a plan update in their new
state at which time, we can provide benefit information under their new plan.
The definition of a referral authorization is:
a) The process of obtaining certification or preauthorization from the health plan for
inpatient or outpatient medical services.
b) The process of obtaining certification or preauthorizations that are for surgical
services only.
c) The process of obtaining a referral from the health plan for outpatient services
provided outside the PCP`s office or network.
c) The process of obtaining a referral from the health plan for outpatient services
provided outside the PCP`s office or network.
You receive a call regarding plan type: MCD. What is your next step after authenticating
the caller?
a) Proceed with the call as normal
b) Offer the member the number to the Medicaid department and Consult transfer
c) Take care of what you're able to, then transfer to Medicaid department
d) Advise the member they have reached the wrong line and end the call
b) Offer the member the number to the Medicaid department and Consult transfer.
Where will you access Find Care to answer Provider-related questions when the
member has a plan with a future effective date?
Where will you access Find Care to answer Provider-related questions when the
member has a plan with a future effective date?
a) Humana.com
b) CRM
c) HSS
b) CRM
c) HSS
a) Humana.com
How are calls involving organ transplant benefits (i.e. heart, kidney, lung etc.) handled?
a) Quote surgery copays via DEBUT.
b) Advise callers prior authorization is required and offer requirements for inpatient
surgery.
c) Warm transfer callers to the Transplant Management Team.
d) Advise callers you can provide in-network Transplant Facilities via Find Care.
d) Advise callers you can provide in-network Transplant Facilities via Find Care.
Where will you find MRI benefit information in DEBUT?
a) Outpatient Advanced Imaging Services
b) Outpatient Radiology
c) Outpatient Diagnostic Procedures
d) Outpatient Lab Services
a) Outpatient Advanced Imaging Services
The definition of a preauthorization is:
a) A market decision defining what services require the provider to contact Humana to
obtain a referral to see someone other than the PCP
b) The process of obtaining certification from the health plan for inpatient or
outpatient services. Often, clinical or medical appropriateness is reviewed
against criteria and assignment of length of stay.
c) A requirement of a PCP to notify Humana when a member is being referred to a
specialist.
b) The process of obtaining certification from the health plan for inpatient or
outpatient services. Often, clinical or medical appropriateness is reviewed
against criteria and assignment of length of stay.
Which tool is used to verify Provider contracts and network information if the accuracy
of the Find Care results is called into question?
a) Provider at a Glance (PAAG)
b) Customer Relationship Management (CRM) System
c) Customer Interface (CI)
a) Provider at a Glance (PAAG)
A member is struggling with finding a Cardiologist that is in network. The member states
they are having trouble with Humana.com and find it confusing.
Select the best process for your next step.
a) Offer to mail a Provider Directory to their mailing address on file.
b) Assist the member by using Find Care and provide contact information as
requested.
c) Show empathy and offer to guide the member through the Find Care tool to help
them understand how it works.
d) Show empathy and advise they will need to keep trying to figure it out.
c) Show empathy and offer to guide the member through the Find Care tool to help
them understand how it works.
How do you handle calls for members seeking to locate a counselor/therapist to receive
mental health counseling for depression and anxiety?
a) Refer to the mental health benefits via the Coverage Issues site
b) Locate the related benefits such as inpatient mental health therapy
c) Transfer the caller to the appropriate Behavioral Health vendor based on their
plan's market
Transfer the caller to the appropriate Behavioral Health vendor based on their plan's market
A member is due for a routine mammogram, but her doctor has recommended that she
get a more advanced 3D scan.
How would you quote this benefit?
a) Quote both Preventive Breast Cancer Screening and Diagnostic Mammography
via DEBUT
b) Quote only Diagnostic Mammography via DEBUT
c) Advise the member an authorization is required for this more advanced testing
d) Quote only Outpatient Advanced Imaging Services via DEBUT
a) Quote both Preventive Breast Cancer Screening and Diagnostic Mammography via DEBUT
Of the plans listed, which is the only Humana Medicare plan that may require a referral?
a) HMO
b) PFFS
c) PPO
d) PDP
a) HMO