Resources
Name the 2 applications that can be used to file an expedited appeal.
Star Central and the QB
KA 2825
When billed under chiropractic services, name 3 services that are not covered.
X-rays, massage therapy and acupuncture.
KA 3245
T or F
We are not required to say all disclaimer verbatim
False
ALL disclaimer should be said in full and verbatim
Nothing beats a what?
Jet 2 holiday
If the caller is not the member, and there is no POA (Power of Attorney) or AOR (Authorization of Representation) on file and the member is NOT on the line with the caller the grievance can still be filed
Fales KA 3109
Caller should advised that AOR form will be sent and must be returned in order to continue the grievance process and/or receive any updates on the grievance.”
Which KA addresses the Medical expense wallet?
Ans KA4312
NB. Most card/balance/ activation inquiries are to be directed to CVS Health by phone –Call 1-844-428-8147 (TTY: 711), 8 AM- 8PM local time, 7 days a week, minus federal holidays.
How do we convert the currency for foreign claims and what is the KA?
We use the OANDA website to obtain exchange rates and convert foreign currency to U.S. dollars for auditing, retention, and consistency purposes unless the claim contains a receipt with the exact exchange rate.
KA 3328
T or F. When doing a outbound call because the call got disconnect. We only need to provide the recording disclaimer?
What is False- KA 2588
We are required to reauthenticate the call.
Name 2 exceptions for compression stockings to be covered under DME
Ans
Burns, wounds, Lymphedema. KA 4212
What deduction does the handling of DSNP/CSNP/Group fall under on the Aetna Scorecard?
Ownership
Calls that are not handled should be connected to the correct dept.
What is the KA for PNC active user unlocking?
PNC: Activate Locked out User. The KA shows the process of unlocking the member’s access.
KA 3105
T or F: If a FL mm is having an issue with eyewear claim, we would then transfer them to Icare since Icare is the delegated eyewear vendor for FL.
FALSE: KA 4333
iCare handles all claims payments to optometrist and ophthalmologists directly contracted with iCare. For all other participating providers that are not part of iCare, the Plan handles all claim adjudication and payment.
T or F. When transferred from a third party like CVS OTCHS. We only need to verify the member name and DOB because we already have the account number populated?
False: we are required to revalidate the call in full
Name 2 exceptions for the offering of the survey and the KA number for survey.
Outbound calls
It is a translation call
The caller hangs up or doesn’t allow the offer.
The caller is in a life threatening or emergency situation.
The caller is clearly under the influence of a substance (Specific requests from Behavioral Health).
The call is a misroute.
The caller is a 3rd party – not authorized to get information on the account.
The caller is another Aetna CSR and / or vendor calling to clarify information about a member.
The caller is calling about deceased member.
The caller does not have a plan with us.
KA 3121 Post Call Survey (PCS)
If the Coverage Determination CD (Request for service to be covered by the plan) /PA/Precertification is denied and the member is upset about this, what should be filed?
This is not a grievance but an appeal. We need to offer appeal rights to the members and offer to file an expedited appeal for them since it is a CD/PA Pre-Certification.
KA 3109
Which KA covers the requirements for documentation?
KA 3658
This covers what is required to be included and has some specifications for certain call types as well.
Who would handle a call regarding the Part B versus Part D Coverage Determination?
Ans: Part D
If it is not apparent whether a drug requires an organizational determination, we should always contact Part D for further assistance.
KA 3663 and 3696
T or F Because CMS are internal Aetna employees (have an Aetna ID) they can attest to gift cards without the mbr being present? T or false?
False KA 3641/ 4207
Only the member, or someone authorized to speak on the member’s account can complete an attestation for the member.
The Utilization Management (UM) team cannot attest on the member’s behalf when the member is not on the line. The member must verbally authorize the UM to complete attestation.
What is the TAT for an ID card to be sent when a PCP was added/change using the PCP error QB.
A new physical ID card will be mailed, it should arrive within 2 to 3 weeks
KA 3210
What is the difference between an appeal and a grievance?
A grievance is a complaint or dispute expressing dissatisfaction with Aetna or a plan vendor related to operations, services, activities and behavior.
An appeal is a formal way of asking Aetna to review and change a coverage decision we've previously made. Examples include: denials for claim, partial claim and precertification.
What is the correct process for 15 EOBs requested by the mm?
Advise mm of the option to print them from the website. Advise the member PHI order form to be completed and sent to Aetna HIPAA Member Rights Team.
NB. In this scenario, the member will not be mailed actual EOBs but claims records instead which contain all the same information the EOBs have.
KA 2576
Name 2 states that receive Home Health Care through Carelon.
Florida, Georgia, Kentucky, Missouri, Ohio, Oklahoma, Texas and West Virginia.
KA 4390
T or F. When sending member materials. We are required to tell the member the address on file to ensure we are sending it to the correct address?
False
KA 2800 We only confirm/validate
T or F we must request the MBI in order to update payment method for Auto Payment via PNC?
False KA 2708
T or F: We are able to file a grievance for terminated/void members once it is within the 60 days and meets the criteria.
True
KA 3109
If the member has been terminated and they have a complaint, make sure that the incident occurred while enrolled and within 60 days and meets grievance criteria. If it meets these criteria, they have a valid grievance. If cancelled retro actively, the same rule applies for cancelled/voided.