Easy
When a hospital is in-network (INN) for a member’s plan, what does this
mean for the physicians that practice at that location?
All physicians are in-network (INN) as well.
A separate physician search must occur to confirm.
None of the physicians are in-network (INN).
I don't know yet
A separate physician search must occur to confirm.
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?
Quote both Preventive Breast Cancer Screening and
Diagnostic Mammography via DEBUT.
Quote only Diagnostic Mammography via DEBUT.
Advise the member that an authorization is required for this
more advanced testing.
Quote only Outpatient Advanced Imaging Services via
DEBUT.
I don't know yet
Quote both Preventive Breast Cancer Screening and
Diagnostic Mammography via DEBUT.
Question
A member is calling in reference to their other insurance. Where in
CRM can you find this information?
Answer
Plan Member Page in the Plan Information tab.
Person Account Page in the HIPAA Forms tab.
Person Account Page in the Interaction History tab.
Plan Member Page in the Additional Details tab.
I don't know yet
Plan Member Page in the Plan Information tab.
Which is the correct method for submitting an appeal to Humana?
Answer
By calling the provider’s office directly.
By submitting a verbal request over the phone.
By notifying the pharmacy in person.
I don't know yet
By sending a written request through Humana.com, the
MyHumana Mobile App, or by mail or fax.
By sending a written request through Humana.com, the
MyHumana Mobile App, or by mail or fax.
Which of the following plans
provider upon enrollment?
requires
a member to choose a primary
Answer
PPO
PFFS
HMO
PDP
I don't know yet
HMO
Which of the following is NOT considered a Medicare covered dental
service?
Routine extractions
A member with an EyeMed Vision plan is calling regarding upcoming
cataract surgery. How do you handle this call?
Answer
Transfer the member to EyeMed and provide the member with
Provide the member with their surgery benefits via DEBUT.
the number.
Advise the member that optical surgery is not covered under
Medicare.
I don't know yet
Provide the member with their surgery benefits via DEBUT.
Which of the following choices best describes a preauthorization?
Answer
A preauthorization is a process where a member pays a fee
before receiving any healthcare services.
A preauthorization is requested by a member's Primary Care
Physician (PCP) or another treating provider and is approved
or denied based on the plan's review to make sure the
requested service is clinically and, or medically necessary.
A preauthorization is a document that allows members to
change their insurance plan at any time.
A preauthorization is a routine check performed by healthcare
providers to confirm a patient's identity.
I don't know yet
A preauthorization is a document that allows members to
change their insurance plan at any time.
Which scenario best describes an appeal?
Answer
A member’s Primary Care Physician (PCP) requests
authorization for a heart procedure, and the request is
approved by the health plan.
A member schedules a heart procedure without seeking any
authorization or contacting her insurance plan.
A member’s authorization request for a heart procedure is
denied, and the member submits a written request to Humana
to have the decision reviewed.
A member’s authorization request for a heart procedure is
denied, and the member submits a written request to Humana
to have the decision reviewed.
A member decides not to proceed with a recommended heart
procedure after discussing risks and benefits with her doctor.
I don't know yet
A member’s authorization request for a heart procedure is
denied, and the member submits a written request to Humana
to have the decision reviewed.
Which tool should be used to confirm the participating status of a
provider when the information shown in Find Care is in question?
Answer
PCP Update/Change Template
CI/PAPI
PAAG
I don't know yet
PAAG
Which of the following is NOT an example of Durable Medical Equipment
(DME)?
Catheter
In CI, which screen is used to verify a member's Rx Other Insurance?
Answer
PEOC
PAAG
SPAM
PGA
I don't know yet
PEOC
Question
Which scenario best describes a referral?
Answer
A member experiencing frequent migraines visits her Primary
Care Physician (PCP), who evaluates her symptoms and
provides a prescription for pain medication.
A member experiencing frequent migraines visits her Primary
Care Physician (PCP), who refers her to a neurologist for
specialized evaluation and treatment.
A member schedules an appointment directly with a
neurologist without notifying her Primary Care Physician (PCP).
A member experiencing frequent migraines chooses to treat
her symptoms with over-the-counter medications without
consulting any healthcare provider.
I don't know yet
A member experiencing frequent migraines visits her Primary
Care Physician (PCP), who refers her to a neurologist for
specialized evaluation and treatment.
Which situation would qualify for an expedited appeal?
Answer
The member is disputing an authorization decision, and
waiting for the standard appeal time frame could seriously
jeopardize their life or health, or their ability to regain
maximum function.
The member disagrees with a claim payment amount but is
not experiencing any urgent medical issues.
The member wants to change their Primary Care Physician
(PCP).
The member needs help understanding their Explanation of
Benefits (EOB).
I don't know yet
The member is disputing an authorization decision, and
waiting for the standard appeal time frame could seriously
jeopardize their life or health, or their ability to regain
maximum function.
Which is the appropriate Classification and Intent (C&I) to select when a
PCP change is successful?
Answer
PCP Change - Not Changed
PCP Change - Research Requested
PCP Change - Change Made
PCP Change - No Change Requested
I don't know yet
PCP Change - Change Made
Which of these Part B plans requires accessing the referral guidance tool
to verify if a referral is required?
MEP (PPO) only
MEP (PPO) and MER (HMO)
MER (HMO) and MRO (HMO-POS)
MRO (HMO-POS) only
I don't know yet
MER (HMO) and MRO (HMO-POS)
Which Medicaid Eligibility level pays Part B premiums only and has
no cost share protection for other Medicare expenses?
FBDE
QMB+
QI
SLMB
I don't know yet
QI
Which scenario is the best example of an authorization request?
Answer
A member schedules an MRI directly with a radiology center
without notifying her PCP or Humana.
A member receives an MRI in the emergency room without
any prior notification to her Humana.
A member’s PCP prescribes medication for pain management
without recommending any imaging tests.
A member’s Primary Care Physician (PCP) determines that an
MRI is needed and submits a request to Humana for approval
before the MRI is scheduled.
I don't know yet
A member’s Primary Care Physician (PCP) determines that an
MRI is needed and submits a request to Humana for approval
before the MRI is scheduled.
What Classification and Intent (C&I) are selected when Appeal Rights and
instructions for filing a written appeal are provided to the caller?
Answer
G&A - Status
G&A - Filing Instructions
Authorization/Referral — Authorization
I don't know yet
G&A - Filing Instructions
Where should you go to locate the PCP Update/Change Template in
CRM?
Answer
CI/PAPI
Find Care Medical
PCP
MARx
I don't know yet
PCP
Which part of Medicare is a glucose meter covered under?
Answer
The member's Part B DME Medical benefit
The member's Part D Prescription Drug plan
It is not covered by Medicare
I don't know yet
The member's Part B DME Medical benefit
The member's Part B DME Medical benefit
Question
How long will beneficiaries have to regain Medicaid status while in
the deeming grace period?
Answer
3 months
9 months
4 months
6 months
I don't know yet
6 months
Which document is used to determine if an authorization is required, and
who manages the authorization?
Answer
Humana Customer Care Preauthorization and Notification List
Referral Guidance Tool
Appeals for Medicare
I don't know yet
Humana Customer Care Preauthorization and Notification List
Arnold doesn't recognize the name of the doctor on the back of his ID
card. Which system would you access to verify why his provider was
assigned?
Answer
Find Care Medical
PAAG
CI/PAPI
Wipro
I don't know yet
CI/PAPI
Who can request a PCP Change for a member?
Answer
Sandra's neighbor, who is concerned about her healthcare
Coverage.
Margarets daughter, who is her POA.
Joe's best friend, who thinks they should have matching plans.
Jill the Humana representative, who works for the local grocer.
I don't know yet
Margarets daughter, who is her POA.