PQ
A member reports that they are having "mistletoe therapy." We wish them a Merry Christmas, and then send them what?
What is a IT-PQ?
Camilla the Chicken has reported pain when she "bawks and clucks," which resulted in a diagnosis of TMJ. She has been a member for two years. Would we send a PVF?
No, we would not. (1 year PVF)
This is the day of the month in which we need all bill problems fixed by to publish things without delay
What is the 15th?
What is "white folder" or "folder"?
Kermit the Frog has had an open Need for being green. However, Dr. Teeth gave him a huge discount for being a cash pay patient, but Kermit's shares had already been assigned. Now he's got more shares than bills. When he calls, we will need to transfer to this department.
What is, "provider relation department"? (We would also transfer if an important comment says to transfer, the member asks about upfront sharing, loss of discounts, if they're confused by PRD communication, or if they ask about Care Compass.)
Beaker the Muppet reports that he has been receiving treatment for "Beep Beep" for the past five years. However, it looks like he is only having follow-up appointments now to monitor his condition. What would we send him?
What is a SOC-PQ?
Kermit the Frog has reported back problems due to carrying the Muppet Show all by himself. He has been a member for 6 months, and the injury occurred 1 week ago. Would we send a PVF for this?
Yes, we would. (1 year PVF)
Similar to the title of a Taylor Swift song "Speak Now," this is the button we should direct members toward when trying to correct a bill problem.
What is "fix now"?
When an old-school postal member has a bill problem, we send them this. (No funny business here, just a straight question! :))
What is a "PRF" or "Problem Resolution Form"?
Miss Piggy is struggling to get the five points of itemization on her bill. She says that a diva should not have to work this hard and wants us to do it. Name a few things we could suggest to her.
1. First we need to insist that she does it, maybe by asking by a different name (superbill, etc.). Then if that doesn't work, ask for a supervisor or for someone at the office to handwrite it.
2. If that doesn't work, then we can talk to our coach and see if PRD needs to take over.
3. If our coach determines yes, we pass it along to PRD. We DO NOT pass it along before then.
An Overlapping Needs PQ.
Rizzo the Rat recently reported a diagnosis of Diabetes - Type 2. He has been a member for 4 years. Would we send a PVF for this?
Yes, we would send a PVF.
Troy and Gabriella sang that it's the "Start of Something New," but this is something we typically do NOT want members to do when trying to solve a bill problem.
What is "submit a new bill"?
SMI has a lot of lingo. Translate these: "Found on NL: NMI - DL explaining sx, rx, and tx & whether or not pre-x." "Found on BL: BNR. DR is ENT; can he tx this?"
"Found on Need Level [comment]: Need More Information - Doctor's Letter explaining symptoms, medication, and treatment and whether or not pre-existing." "Found on Bill Level: Bill Not Related. Doctor is Ears, Nose, and Throat; can he treat this?"
Ebenezer Scrooge has Medicare and SMI. His surgery costs $15,000, and HCBB says the fair price is $7,000. However, Medicare is willing to pay $10,000, which means there is only $5,000. Now, Scrooge does not want to pay a dime, of course, and submits this to SMI. With a proper screenshot, we could offer him what?
Gonzo is suffering from breathing problems. Upon sending a PVF, the doctor reports that the problem is his long beak, which is pre-x. However, Gonzo pushes back and says that his long beak is not the issue, but that this is something new. What would we send?
We would send a Pre-Existing Clarification PQ.
Statler recently discovered he has asthma after experiencing an attack while making fun of Fozzie's latest comedy act. He has been a member for 2 years. Would we send a PVF?
Yes, we would. (3 year PVF)
Though we usually hate when GP or GH have to do this, what is something we always need to ask the member and then do at the end of a Needs phone call?
What is "ask for a condition update"?
Nemo has been out of town for a year but has a bill to submit for his lucky fin, which needed surgery. It is currently 5/30/2003; the bill is from 1/6/2002. Is there something we can find for Nemo that might help him? This is the first time he's ever held onto a bill this long.
We could offer him an OTE.
Dory is extremely forgetful. She has two procedures: an x-ray at the ER for a broken fin, and then a surgery to repair her broken fin. She submits screenshots for both of these to get the FPR, because she can't remember what does and doesn't qualify. Would we be able to accept both these screenshots?
No, we would not. Luckily for Dory, though, we only need one to qualify, but the ER charges + x-ray are not eligible.
Waldorf has been receiving joke therapy from Fozzie the Bear; however, he has now reached the limit of therapy and a check-up proved that Fozzie's bad jokes actually aggravated Waldorf's condition. He is seeking out a new comedian, but will need more therapy. What would we send?
It turns out that Rizzo the Rat's diabetes is actually Type 1, not Type 2. He has been a member for 4 years. Would we send a PVF for this?
No--Type 1 diabetes is a 1 year PVF, while Type 2 is a 5 year PVF.
Though typically used to describe Barney the Dinosaur, at SMI, we also use this to refer to something when a member responds to a folder incorrectly or when a solution might be more complex.
What is "purple," "purple folder," or "problem task"?
Waldorf is an advocate and Statler is a processor here at SMI. Statler approved something that Waldorf thinks shouldn't be shared. The two can't come to an agreement, so now this needs to happen.
This is not just a employee of a hotel that might help you make restaurant reservation, but also someone who might help members get the FPR.
What is the "HCBB concierge"?