SYSTEMS
Name a website that I would go to read information about a Preauthorization.
CareCore (Evicore)
Medcompass
GPS
Where in GPS would I go to locate a cardiologist for the member?
Find Care
What are the 2 types of an appeal?
Expediated and Standard
What does HRP stand for?
Health Rules Payor
True or false?
We can view Appeals in GPS
True
What is the turn around time for an expediated appeal?
72 hours
Where would I go to file an expediated appeal?
Stars Central Portal
Name one next best action alert in GPS
Care Management
Healthy Home Visit
Online Self Service Registration
What is the turn around time for a standard appeal?
30 days
If the member faxed or mailed something in where could I locate that information?
ECHS
IOP/Document Viewer
Fax Central
Where could I locate if the member has Medicare Part A or B in GPS ?
Medicare Attributions
How can a standard appeal be filed?
In writing or online
Tell me the guided workflow in finding a RUMBA Rate Inquiry?
HMOPROD
MR-CLS1
USCLIMNQ
PSRCINQ
PSRRATE1
If a pop up occurs for an authorized caller on a members GPS case do we still need verbal authorization from the member or can we proceed with the call?
Bonus: What is the form called to have a dedicated person on the members account?
Verbal authorization is not required when the member has an authorized person on the account.
PHI (Personal Health Information) Form
Name the 5 Levels to an appeal
Level 1: Reconsideration through Aetna
Level 2: Independent Review Entity (IRE)
Level 3: Administrative Law Judge Hearing (ALJ)
Level 4: Medicare Appeal Council
Level 5:Judicial Review