Benefits
How do you know if a 3D mammogram is covered?
Check IBAAG under preventive or physician office. You will know if they are covered if IBAAG is either silent or there is specific language referencing coverage. They are typically covered unless there is language stating that they are not. Good SDM topic!
Why would you ask a member to obtain a provider tax ID or why would you reach out and obtain one?
If you can't find a provider in IBAAG, Rally or the National Ancillary Provider List Sometimes providers bill under another name and the only way we can find them in the system is under a tax ID number.
What part of the member's health history do you collect when you enroll someone in a Call One (Case Management) Program?
One condition. The case manager will collect a full health history.
A member calls in with hip pain. What do you need to check on the dashboard before you proceed?
Whether the member has Orthopedic Health Support. If the member does, refer (Call One) to OHS for both SDM and program enrollment. If the member doesn't want the transfer, try SDM on your own to see if they will at least accept education from you.
A member calls in and states they are traveling to Japan. He is worried about contracting the Japanese Encephalitis Virus. The question is whether travel vaccines are covered under their plan. Where would you check first? Where would you tell the member to go for the vaccine?
Check the preventive section in IBAAG. Control F Vaccine. Since vaccines are preventive. Also Control F foreign so you can quote the foreign and international claims section. Check the Preventive Care Services Coverage Determination Guidelines and Control F Japan or travel. Tell the member to check out UHC's travel insurance at uhcsafetrip.com (for purchase) and tell them they can Google passporthealthusa.com: While Passport Health does not accept insurance, we do offer to submit a claim to your insurance provider at many of our clinics. In some case, a small fee for this service is applied. We also provide you with a receipt that has all the information needed for you to submit your claim.
Is Mirena covered as a preventive benefit? Where would you check this?
If the member has preventive benefits in IBAAG, the Mirena IUD is covered. You would verify this by checking the Preventive Care Services Coverage Determination Guidelines in the Benefit and Coverage SPA.
What system would you use to look for a lactation consultant? What do you say to a member if you can't find a provider in that system? What do members pay for a lactation consultant visit?
Look for a lactation consultant in Rally. If you can't find one, tell the member to contact their OB/GYN or a local hospital to obtain a name. Check to see if the member has the expanded women's health benefit in IBAAG. Also check out the preventive benefit guidelines.
What three things do you check in ICUE after you offer case management? Where is this information found? Why are you checking it?
The autodialer found on the Member Summary Tab. You are checking it to make sure the member does not receive ongoing calls about enrollment. On the member summary tab, also update the member's phone number and email address, especially if you enrolled them in a program.
If you are 23 years old, how often is it recommended that you have a cervical cancer screening test and where would you find this information?
Every three years. You can find it in one of two places, the preventive benefit document in the Benefit and Coverage SPA or in the SDM tool under "When Does This Make Sense".
What do you do if someone calls in and repeatedly says "Spanish"?
You tell the member you will call the language line for an interpreter. In VCC, type in Language and use the WARM CONFERENCE button and carry on with the call.
What is COBRA?
COBRA is insurance that is offered to employees who leave their company. It is often expensive. The member pays the entire premium. It typically lasts for 18 months. The COBRA insurance is managed by a third party vendor. The member will receive a packet in the mail from the COBRA vendor couple of weeks after they leave the company. If they choose COBRA, it will be backdated to their last covered day with UHC while they were employed. The member pays the COBRA provider and the COBRA provider lets us know the member has paid the premium.
Why do we want to rely on ISET as much as possible when conducting a provider search for people and large facilities?
We want to rely on ISET because Rally may not have special network requirements that you would find in ISET under the Market Type on the Eligibility tab.
What site do you check outside of ICUE, whether a member declines or enrolls in a program and why?
Check Avaya to ensure that the member is not going to be called again about enrollment.
A female member is 38 years old and has a family history of colon cancer. Her GI doc wants to do a colonoscopy. Would the colonoscopy be covered as preventive? Where would you find this?
Check the Preventive Care Services Coverage Determination Guidelines. It states on page 4, the study would be diagnostic because:
does not fall within the applicable population for a recommendation or guideline (e.g., someone who has a colorectal cancer screening due to a family history).
Where would you check if someone calls in and states they need a wig after chemotherapy?
Check IBAAG to see if there is any coverage for wigs by using Control F wigs. Sometimes there is coverage and sometimes there is not. There are not very many wig vendors. If there is coverage, the member will probably obtain the wig from a salon and can file for a gap exception. You will be emailed a list of wig providers. Gap exceptions MUST occur before purchase.
What is UHC's Hearing Aid Vendor?
hi Health Innovations. You will see it in IBAAG, if the member has it. Sometimes it is at the very bottom of IBAAG. Many hearing aid providers (Costco, Miracle Ear, local hometown vendors) do not participate with UHC because they want to charge and receive billed charges with no discount. If you see the hi Health Innovations in IBAAG, tell the member all about it.
A member calls in and says she needs oxygen. Which vendors would you refer her to and where did you find the information?
Apria, Lincare and Rotech on the National Ancillary Provider List.
Besides entering conditions, what else do you fill out in ICUE when you enroll someone in a Call One case management program (OHS, GCM, Maternity)?
The assessment. If you miss the link access the assessment from another tab and complete drop downs (Commercial/Optum Health)
What would you say to a female member who calls in and asks if a screening for osteoporosis is covered? The member is 48 years old and had a hysterectomy two years ago. What document could you check?
Check the Preventive Care Services Coverage Determination Guideline Document. It states on page 16:
USPSTF Rating (June 2018): B
Women 65 and older
Postmenopausal women younger than 65 years at increased risk of osteoporosis
How do you save an ORS in ISET, you transfer a member to a Tier 2 agent?
Look in the A4Me Tier 3 Claims Call Handling Process SPA in Knowledge Central.
Save the call as Misdirected Call/MISD-Other in the ORS saving drop downs.
Other misdirected calls not related to a CLAIM can be saved using the red and blue arrow function in ISET.
What do you do if a parent calls in and says their child is 26 or older and is handicapped? The parent wants their handicapped child to continue with UHC coverage? What SPA would you check?
Check the Eligibility SPA. There is a tile just for Handicapped Children. Send the member a handicapped child form to complete and send back. Follow the steps listed on Health Advisor and Specialty Benefits Fulfillment tile in the Building Trust Through Advocacy SPA. Click on this link to find the form to send. http://apset4592.ms.ds.uhc.com/LaserOrderingSystem/
What pharmacy can I use to obtain a flu shot? Where did you find the list? What benefit applies to vaccines, pharmacy or medical?
Click on the link below to see the contracted pharmacies that can give vaccines. Vaccines apply to the medical benefit, even if they are received at a pharmacy. Check IBAAG for preventive benefits.
Name at least five best practices to review with a member during a Call One program enrollment.
In any order:
(1) Nurses' name and time/date of appointment (2) be available 30 minutes before and after the scheduled time (3) Caller ID may show UHC, area code 952 or a 1-800 number (4) be ready to provide meds, conditions, allergies and providers (5) We will send you a reminder about your call (6) The case manager will verify HIPAA when she calls you (7) The nurse will give you his/her direct dial number (8) Call the number on the back of your card to reschedule or to change nurses.
A member calls in wanting information about code 73222 and how it would be covered (prior authorization, high level benefit in IBAAG, and pricing)? How would you handle this request?
(528939062)
Look up the code in KL just to confirm the service. Click on the MED NEC tab at the top of ISET. Check IBAAG. Since they don't match, call Radiology services as the tie breaker. Check the Cost Estimator Tool in ISET for an ESTIMATE. Transfer to Tier 2 for PRICING.
Question #1: What do you do if a member calls in talking about a motor vehicle accident or workers comp?
ALSO
Question #2
If you don't see RAPS in a fully insured (FI) IBAAG what do you tell the member?
#1 Transfer them to subrogation. Subrogation is a special department that coordinates claims payment with outside entities like car insurance companies and worker's comp companies who may be responsible for paying the claims instead of UHC.
#2 Just remember that all fully insured members have RAPS, whether their IBAAGs state it or not.