OOA
What OOA network should a member use if they are in Washington?
UHC
True or False? If a parent calls to schedule an appointment for 3 kids on Medicaid, you must track it in all 3 policies.
True
What DX code should you use if the caller does not have one?
Z00
How much would I have to pay for spine surgery?
Member Services
What is different about Medicare members’ names in Facets or EMC compared to other SH plans?
The names are lower case instead of caps
If a member lives in a gap area, where should an Advocate find them a provider if there are not many or any options in PDA?
From the appropriate OOA network according to their location (MultiPlan, PHCS, Beech Street)
When a Medicaid member is calling for an eye exam, what provider type should we look for first and why?
Optometry - no copay
List an example of a nonpar review that an Advocate can automatically entered in CareRadius without offering in-network options.
Kathleen Pfeffer, Lucinda Bateman, etc. (see answers on Auto Entry handout)
How can I set up auto pay for my premium?
Premium billing
What are the 4 gap areas in Utah?
Carbon, Emery, Grand, & San Juan
The member on under policy ID#801371700 reaches Advocates and is requesting care options for a detox facility. How do you handle the call?
What does the subject, category, and summary need to be in Facets when transferring a call to the nonpar line?
Nontrackable Calls/Transfer Call Left Message/NP XFER
I don’t understand this claim I received.
Member Services
What does a member rep need to have in order to start a nonpar review for a Medicare member?
AOR form
Does the Harmon's City employer group allow OOA dependents to receive participating benefits while they live out of area?
No
What care options would you give a Medicaid member who is traveling in Montana and believes he has an ear infection?
ER or to return to service area
Which NPR requests should be transfered to the NPR line?
Medicare, ID, npr status questions
Can you help me find a doctor for bariatric surgery?
Health Services
What kind of Medicare inquiries MUST be escalated to the Appeals department?
Quality of care, foreign language and cultural sensitivity, and sales allegations
Joe is a member calling on vacation in California. He says he is experiencing some eye irritation and wants help finding an eye doctor to check him out. He’s on an L20C plan.
a. What SelectHealth plan is the member on?
b. Which network(s) must the provider be participating on?
c. Will this visit be INN, OON, or not covered?
a: Large Employer Care +
b: UHC
c: INN
The member under policy ID#801030261 reaches Advocates and states that she wants to start a NPR for an out-of-network orthopedic surgeon. How do you handle the call?
Transfer to HC / Care Manager line
Name two NPR situations that are considered automatic denials.
PCPs
MBR Preference
Routine services
My stomach has been hurting for the past few days and seems to be getting worse but I don’t know if I should wait for my doctor next week or go to the ER.
Health Answers
What are the four parts of Medicare and what do they cover?
A - HOSPITAL
B - MEDICAL
C - ADVANTAGE
D - DRUGS