Compliance & Regulations
AEP Basics
Job AIDs
Pharmacy
KC Search
What Would
You Do?
You Do?
100
This is a U.S. federal law designed to protect sensitive patient health information and ensure its secure handling by healthcare entities.
What is HIPAA?
100
This is the time frame for AEP 2026.
What is October 15 to December 7, 2026?
100
What Articles provide requirements and guidance for properly authenticating a caller and protecting the privacy of our members?
100
Member wants to know the price for a Medication what JA will you use?
100
If a member has a PPO Plan with INN and OON benefits and wants to assign a OON provider, what JA would you use for help?
100
Member has a prescription for Belbuca what is needed to get the prescription filled?
Coverage Determination
200
This is the consequence of giving incorrect plan info.
What is a compliance violation or CMS audit? (CTM)
200
This is TAB to verify member's plan for 2026 and if it is the same plan as the current plan; check the contract, PBP, and segment number for the next year’s plan with the current plan.
What is Plan Tab?
200
What JA gives you the reason for NOT presenting NBA’s?
200
What JA helps with LIS and level information?
200
What JA would you go to for Unauthorized Transactions on a Ucard?
200
Member calls and needs a shower chair. What is needed to be done.
Nothing a shower chair is not covered the member can use their OTC benefits to get the shower chair
300
This is a request to have the plan change a decision for a denied prior authorization or claim.
What is Appeal?
300
This document outlines changes to a member’s plan for the upcoming year.
What is the ANOC (Annual Notice of Change)?
300
This is how we stay aligned and informed throughout AEP.
SOP, updates and change champ emails.
300
This is the timeframe when coverage changes made during AEP take effect.
What is January 1, 2026?
300
What JA would you go to for NBA ANOC?
300
member calls and said the doctor said he needs a Bariatric Walker what steps need to be taken.
follow the steps in the Complaints and Grievances Tab
400
When can we start discussing plan changes with existing members who have received their ANOC for 2026
What is after September 1, 2025?
400
This is the deadline for plans to send ANOC to members.
What is September 30?
400
What JA do you need if a member calls in about premium payment options
400
what job aid is the Pharmacy one source of Truth
400
Where can you find information on KED Test Kits for our members? KM?
400
If the members daughter calls in and demands we change the members address because the member now lives with her (but the member is not available) and is the authorized user, Can you change the address?
500
This is the formal decision a Medicare Advantage plan makes about whether a requested service or item will be covered or paid for.
What is an Organization Determination?
500
This is whether an eANOC can be sent again or used as a replacement.
What is no?
Replacements are sent via mailing address on file.
500
This is the best way to handle a tough call or situation during AEP. hint: SOP
500
What JA do you use to explain Part coverage levels
500
What KM would you use for help on updating member’s Rx COB?
500
Ms. Bea called and said her Kidney doctor, Dr Horton is no longer in network, but she was receiving Treatments from him for her kidney condition and would like to continue seeing him what can be done
KM2053500