Provider Network Inquiry
What plan types could you educate the member on?
ESA PPO, PPO, or HMO
What tools can be used to educate precertification status?
Medcompass and/or Evicore/Carecore
What Knowledge Articles can you use to review the reimbursement process for Group members?
KA 3303 Hearing Aids
KA 2778 Member Reimbursements
KA 4105 Post Cataract Eyewear
The member has called to review a precertification status for a knee replacement, what unasked questions can we educate on?
MOOP/Deduct status
Benefits for the service
Probing questions to determine if member will need rehabilitation services and/or DME
Where can you find the Find Care Disclaimer?
KA 3097
What would you educate if a precertification is present?
Educate on status (approved, denied or pending).
Educate on precertification turn around times.
Where can you confirm the members allowance amount and if it has been used or not?
Benefits/accumulators to review allowance
Accumulators to confirm if allowance available
You have provided the member with a new PCP provider and have provided the members MOOP/deduct status and plan benefits. What additional unasked questions can we educate on?
Offer to contact the provider to review the plan, see if they are accepting new patients, appointment availability.
When locating a provider or list of providers what can we educate the caller on?
Network Participation, Provider Name/addresss/phone, accumulators/benefits.
If precertification is is or isn't present what additional items should you be educating?
Educate on accumulators and benefits even if precertification is not on file.
Once confirmed the member has an allowance for reimbursements, what should we be educating?
Educate on allowance amount/status. Educate on reimbursement status.
The member has called request a replacement ID card and a claim reimbursement form. What can we educate the member on?
If mailing an ID card educate on 8-10 days when placing the order on the call. The turnaround time for a form mailing is 7-10 business days (KA 2591 and 2800)
Should you click the SR box next to each provider given to the caller and why?
Yes, because it simplifies documentation on the call.
If precertification is not present what should be educated to the caller?
Advising no precertification is on file, offer to reach out to the provider to confirm 1. what is the CPT code to verify if precertification is needed and 2. if needed to educate the provider that they will need to submit for precertification.
What should you educate on how to submit for member reimbursement?
The member has called to see if they have the Extra Benefits card like their neighbor, what can we educate that wasn't asked directly by the member?
Use KA 4129 to determine eligiblity
Educate on VAIS benefits (KA 4195 and 4196)
When should you offer to call a provider when educating on provider networking questions?
Anything that removes the member from the middle for example, scheduling an appointment, educating on members plan, if they are accepting new patients, etc.
What do we educate the caller when a precertification is denied?
KA 2825 Regular Expedited Appeals
KA 3003 QIO Expedited Appeals
How can a member submit a reimbursement claim?
Online, by fax or by mail.
The member has called about coverage for cataract surgery, what unasked question can we educate the member on?
POST CATARACT SURGERY EYEWEAR
After cataract surgery with intraocular lens insertion, we will cover one pair of conventional glasses or contact lenses; this applies to all Medicare Advantage members whose plans include this benefit.