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 4235
Nothing beats a what?
Jet 2 holiday
T or F: Because Case managers are internal Aetna employees (have Aetna ID) they can attest for gift card without the mm being present?
What is False KA 4391/3641
Important Note: Only the member, or someone authorized to speak on the member’s account can complete an attestation for the member.
Which KA addresses the Medical expense wallet?
Ans 4312
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: It is necessary to confirm the phone number with the member on every call?
What is False- KA 4254 If phone numbers on the CTI pop match phone numbers on the member’s file, no need to verify.
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 3015
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: If a mbr has lost their MBI Card we would advise them to reach out to Social Security at 800-772-1213
What is False direct them to MEDICARE 1-800-633-4227 - KA 3666
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
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.
T or F: We are able to file a grievance for terminated/termed/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.