Easy
A member calls saying, “I need to see a dermatologist due to a recent skin problem flare-up. Can you tell me what that’ll cost? I’m nowhere near paying off my deductible, so I’m a little worried.” You notice in DEBUT that specialist office visits are included on the list of deductible exclusions for his plan. His accumulators show that he has $550 left to pay toward his deductible. As an Advocate, what would you tell a member?
You’d pay $45 for a visit to an in-network dermatologist but 50% of the total cost if out-of-network. These benefits apply even though you haven’t met your deductible.
When a hospital is in-network (INN) for a member’s plan, what does this mean for the physicians that practice at that location?
A separate physician search must occur to confirm.
Which of the following is NOT considered a Medicare covered dental service?
Routine extractions
Fracture of the jaw or facial bones
Extraction of teeth to prepare for radiation treatment of neoplastic cancer diseases
Setting fractures of the jaw
I don't know yet
Routine extractions
Which of the following is NOT an example of Durable Medical Equipment (DME)?
Catheter
Wheelchair
CPAP
Machine
Walker
I don't know yet
Catheter
Which of these Part B plans requires accessing the referral guidance tool to verify if a referral is required?
MER (HMO) and MRO (HMO-POS)
MEP (PPO) only MEP (PPO) and MER (HMO)
MRO (HMO-POS) only
I don't know yet
MER (HMO) and MRO (HMO-POS)
Which part of Medicare is a glucose meter covered under?
The member's Part B DME Medical benefit
The member's Part D Prescription Drug plan
It is not covered by Medicare
I don't know yet
The member's Part B DME Medical benefit
A member is due for a routine mammogram, but her doctor has recommended that she get a more advanced 3D scan. How would you quote this benefit?
Quote both Preventive Breast Cancer Screening and Diagnostic Mammography via DEBUT.
Quote only Diagnostic Mammography via DEBUT.
Quote both Preventive Breast Cancer Screening and Diagnostic Mammography via DEBUT.
A member with an EyeMed Vision plan is calling regarding upcoming cataract surgery. How do you handle this call?
Provide the member with their surgery benefits via DEBUT.
Transfer the member to EyeMed and provide the member with the number.
Advise the member that optical surgery is not covered under Medicare.
I don't know yet
Provide the member with their surgery benefits via DEBUT.
In CI, which screen is used to verify a member's Rx Other Insurance?
PEOC
PAAG
SPAM
PGA
PEOC
Which Medicaid Eligibility level pays Part B premiums only and has no cost share protection for other Medicare expenses?
QI
FBDE
QMB+
SLMB
QI
How long will beneficiaries have to regain Medicaid status while in the deeming grace period?
6 months
3 months
9 months
4 months
6 months
A member is calling in reference to their other insurance. Where in CRM can you find this information?
Plan Member Page in the Plan Information tab.
Person Account Page in the HIPAA Forms tab.
Person Account Page in the Interaction History tab.
Plan Member Page in the Plan Information tab.
Susan is calling as a courtesy to inform us that her Rx Carrier has changed. Which classification and intent should be used to document this call?
COB::Rx Update/Dispute
COB::Medical Update/Dispute
COB: Verification
COB::Rx Update/Dispute
Which of the following choices best describes a preauthorization?
- A preauthorization is a document that allows members to change their insurance plan at any time. - A preauthorization is a process where a member pays a fee before receiving any healthcare services. - - A preauthorization is requested by a member's Primary Care Physician (PCP) or another treating provider and is approved or denied based on the plan's review to make sure the requested service is clinically and, or medically necessary.
A preauthorization is requested by a member's Primary Care Physician (PCP) or another treating provider and is approved or denied based on the plan's review to make sure the requested service is clinically and, or medically necessary.
Which scenario best describes a referral?
A member experiencing frequent migraines visits her Primary Care Physician (PCP), who refers her to a neurologist for specialized evaluation and treatment.
A member experiencing frequent migraines visits her Primary Care Physician (PCP), who evaluates her symptoms and provides a prescription for pain medication.
A member experiencing frequent migraines visits her Primary Care Physician (PCP), who refers her to a neurologist for specialized evaluation and treatment.
Which scenario is the best example of an authorization request?
A member’s Primary Care Physician (PCP) determines that an MRI is needed and submits a request to Humana for approval before the MRI is scheduled.
A member schedules an MRI directly with a radiology center without notifying her PCP or Humana.
A member’s Primary Care Physician (PCP) determines that an MRI is needed and submits a request to Humana for approval before the MRI is scheduled.
Which document is used to determine if an authorization is required, and who manages the authorization?
Humana Customer Care Preauthorization and Notification List
Referral Guidance Tool
Appeals for Medicare
Humana Customer Care Preauthorization and Notification List
Which document is used to determine if a referral is needed?
Referral Guidance Tool
Humana Customer Care Preauthorization and Notification List
Appeals for Medicare
Referral Guidance Tool
Which is the correct method for submitting an appeal to Humana?
By sending a written request through Humana.com, the MyHumana Mobile App, or by mail or fax.
By calling the provider’s office directly.
By submitting a verbal request over the phone.
By sending a written request through Humana.com, the MyHumana Mobile App, or by mail or fax.
Which scenario best describes an appeal?
A member’s authorization request for a heart procedure is denied, and the member submits a written request to Humana to have the decision reviewed.
A member’s Primary Care Physician (PCP) requests authorization for a heart procedure, and the request is approved by the health plan.
A member schedules a heart procedure without seeking any authorization or contacting her insurance plan.
A member’s authorization request for a heart procedure is denied, and the member submits a written request to Humana to have the decision reviewed.
Which situation would qualify for an expedited appeal?
The member is disputing an authorization decision, and waiting for the standard appeal time frame could seriously jeopardize their life or health, or their ability to regain maximum function.
The member disagrees with a claim payment amount but is not experiencing any urgent medical issues.
The member wants to change their Primary Care Physician (PCP)
The member is disputing an authorization decision, and waiting for the standard appeal time frame could seriously jeopardize their life or health, or their ability to regain maximum function.
Which is the correct first step when researching an appeal in CRM?
Begin by reviewing the CRM case comments for the appeal along with the information found in the Grievance and Appeal Status Quick Link.
Ask the member for details about the appeal.
Ensure the caller that the appeal is being handled.
Begin by reviewing the CRM case comments for the appeal along with the information found in the Grievance and Appeal Status Quick Link
What Classification and Intent (C&I) are selected when Appeal Rights and instructions for filing a written appeal are provided to the caller?
G&A - Filing Instructions
G&A - Status
Authorization/Referral — Authorization
G&A - Filing Instructions
Arnold doesn't recognize the name of the doctor on the back of his ID card. Which system would you access to verify why his provider was assigned?
CI/PAPI
Find Care Medical
PAAG
CI/PAPI
Which of the following plans provider upon enrollment?
HMO
PPO
PFFS
HMO