T1

HIPAA

100

List all the Unique Member ID Number that can be used in order to proper authenticate a call.

Member ID

Medicare/Medicaid ID#

Payment ID# (PID - available on their coupon book) 

Social Security Number

200

Describe the complete process for obtaining the member's verbal consent.

1. Ask permission to speak directly to the member to obtain verbal consent to release the information.
2. Once the member is on the line, have the member state their name.
3. Confirm that the member gives verbal consent to the caller.
4. Explain that the consent is only applicable during this one call occurrence.
5. Select the box of "Verbal Consent Obtained" in QuickStart+

300

What are the types of request that a member can provide to authorize someone to speak on their behalf?

verbal or written consent

400

Which is the only excepton that allows to provide the member´s Medicare ID number?

When the provider needs the Medicare ID# for billing purposes (after authentication)

500

What is the legal document that takes place of a POA after a member dies?

Executor of Estate

BENEFITS

100

What should be included in a call to complete the VOB Cycle?

verify the plan type, benefit requested is available, the provider is in network, accumulations and if an authorization/referral is needed

200

What are 3 Eligible Trips under the Transportation Benefit?

Non-emergent, plan cover and medically necessary, and trips to pharmacy locations to pick up prescription

300

Which tool from CRM is used to check additional details regarding specific services or plan exclusions?

Debut

400

Which are Humana's preferred diabetic DME supply providers?

CCS Medical and Edwards Healthcare

500

Under which benefit should you quote a Blood Pressure Monitor?

OTC benefit

PHARMACY

100

Which tool should is used when you need to view the amounts applied to each benefit stage for a specific medication?

RX connect pro and RX Nova call connect

200

What are the fill days limit when an opioid prescription has been rejected because of the Exceeds Opioid Initial Fill Limits error?

First time they're receiving opioid medications and a member who has not used opioids for more than seven consecutive days during the previous 30 days is limited to no more than a 7-day fil.

300

What Drugs are not allowed for tier exceptions?

tier 1 drugs

400

What is the tool used for pharmacy claims?

RxNova Call Connect

500

What C&I would you use for a member who called to see the status of her pharmacy PA?

C: Rx

I: Prior Authorization

Prio Authorization

100

What is the time Frame for a Normal and an Expedited Medical Authorization/ Referral?

• Non-urgent/non-expedited preauthorization requests, the time allotted is as quickly as possible not to exceed 7 calendar days.
• Urgent/expedited requests, the time allotted is not to exceed 72 hours. These are actual hours and not business hours.

200

Name the mentor document used to check which vendor handles the PA?

Business Partner (Vendor) Information List

300

Name the mentor used to check if a member needs a referral

Referral Guidance Tool

400

Name the mentor document used to check if a medical procedure requires a PA

Humana Customer Care Preauthorization and Notification List

500

What details can we find in the Provider Information section when checking a Referral Status in CRM?

Type, name, street, city, state, ZIP code, phone, Tax ID, humana provider ID, participating status