HIPAA
What does HIPAA stands for?
Health Insurance Portability and Accountability Act
In which system can the resolution of a grievance submitted on November 5, 2024, be found — CSIM or CRM?
CRM
Do we have to offer the Eliza Survey to a caller with Verbal Consent? True or False
True
How long is the AOR form valid once it has been signed by the member and the representative?
The form is valid for 1 year.
_____________ are terms used to describe different types of misconduct, negligence, or misuse that can occur during the provision of medical services and payment of medical claims, whether intentional or unintentional.
Fraud, Waste, and Abuse
If you forget to offer the Eliza Survey, do you have to open the STC C0283? Yes or No.
No
Which STC should you use if the caller can't be verified?
STC CP435 – Unable to authenticate
True or False: A DOH (Designation of Healthcare Surrogate) can submit a grievance on the member's behalf.
True
Why is important to leave the Organization Determinations in Open Status?
Because leaving it close may delay our Auths department from receiving the case, affecting member's health and being out of compliance.
True or False: You can disclose the summary of benefits to any caller, even if they are not authorized on the account.
True
What is the service center that we use when a grievance is submitted by an invalid requestor?
Louisville
What is the process we must follow to refax an authorization to a provider?
Requests to Refax Medical Approval
In what year was the HIPAA law enacted?
1996
True or False: A grievance for transportation benefit reinstatement will be resolved within the next 72 hours.
False
If a member wants to cancel their plan that will be effective the next month, what process should be followed?
Cancellation of Enrollment Application Process