Child Questions
(NTC ONLY)
(NTC ONLY)
Difficult Provider
Difficult Members
ALL ABOUT
CENTENE
CENTENE
Nebraska Total Care
100
What is the plan called that covers pregnancy?
599 Chip
100
Provider states they couldn’t submit claims due to portal downtime and now face late filing risk.
✅ Step 1: Lead with Empathy
Avoid minimizing the issue.
Effective Response:
“I understand how concerning that is, especially when filing deadlines are involved. If the portal was unavailable, that absolutely can create stress around claim submission.”
This reduces defensive escalation immediately.
✅ Step 2: Verify the Details
Gather:
Date(s) portal was unavailable
Screenshot or reference number (if available)
Claim DOS and timely filing deadline
Whether alternate submission method was attempted
Then check:
Confirmed outage logs
Official downtime notice
Duration of service interruption
✅ Step 3: Confirm Impact on Filing Deadline
Clarify:
Original timely filing limit (e.g., 90 days, 180 days, 1 year)
Whether claims are already denied or at risk
How many claims are affected
Avoid saying:
“You’re still responsible for filing on time.”
Instead say:
“If the outage occurred during your available filing window, we can review this for a timely filing exception.”
✅ Step 4: Offer Solutions
Depending on policy:
🔹 Option A: System-Wide Outage Confirmed
Inform provider an exception/extension applies
Provide instructions for submission
Add internal documentation note
Provide reference number
Example:
“I do see confirmation of a portal outage on March 1st from 8 AM to 4 PM. I’ll document your account to ensure timely filing exceptions are applied to claims impacted during that timeframe.”
🔹 Option B: Outage Not Documented but Reported
Escalate to technical support review
Create incident ticket
Advise submission with proof of attempted filing
Example:
“I’m going to open a technical review to verify what occurred. In the meantime, you can submit the claims and include documentation of the attempted submission.”
🔹 Option C: Filing Deadline Has Already Passed
Guide through appeal process
Clearly explain required documentation
Offer escalation if financial hardship exists
🚫 What NOT to Do
Don’t imply provider fault
Don’t say “You should have used another method” without verifying availability
Don’t default to automatic denial language
Don’t dismiss single-day outages as insignificant
correct answer = 300 points!
100
How do you open your call?
CONGRATS!! YOU GET 300 EXTRA POINTS!
100
What is your favorite part of working for CENTENE?
YOU GOT DOUBLE POINTS!
100
This value added service is used to assist members to get back and forth from appointments?
MTM
200
What all can a member receive with the pregnancy rewards?
Car seat
Stroller
Pack and Play
Meal delivery of 10 meals
200
Do we create letters to be sent to the provider for reconsiderations?
Nebraska Total Care is not required to create a determination letter for a Reconsideration. We sometimes do for Reconsiderations submitted via the portal, but it’s not required. If the team that works the Recon does not create a letter then PR cannot request it. It won’t be created. If the call center does not see a determination letter in Omni for a Reconsideration one will not be created by sending to PR. If a letter was not generated, the claim should reprocess with either an adjudication status of upheld or the new adjudication status. If the claim does not reprocess, PR can submit a claims case to ask that it be reprocessed. If there is a letter in Cenpas/dauntless, PR can save it and email it. We will never fax a letter. We do not have access to a fax machine.
200
A member who struggles with English has been transferred multiple times and is now upset and confused.
✅ Step 1: Immediate Ownership & Reassurance
Avoid: “Let me transfer you to the correct department.”
Instead: “I’m sorry you’ve been transferred several times. I will stay with you and make sure we get this resolved.”
This reduces panic and rebuilds confidence.
✅ Step 2: Assess Language Needs Respectfully
Use simple, clear language: “Would you like an interpreter to help us talk?”
Do not:
Ask them to bring a family member
Continue complex explanations if they are struggling
Speak louder instead of clearer
If interpreter is requested:
Stay on the line during connection
Brief interpreter clearly
Continue addressing the member directly (not the interpreter)
✅ Step 3: Simplify Communication
Use:
Short sentences
Plain language
One topic at a time
Yes/no confirmation questions
Example: “Your claim is still being reviewed. It is not denied. It is still being checked.”
Pause frequently and confirm understanding:
“Does that make sense?”
✅ Step 4: Minimize Transfers
If another department is needed:
Warm transfer (stay on line and explain issue)
Brief next agent clearly
Ensure member doesn’t repeat entire story
Confirm interpreter remains connected
Example: “I will stay on the line and explain everything so you don’t have to repeat it.”
correct answer= double the points!
200
What is this week called on CNET?
CENTEAM APPRECIATION WEEK!
200
This department can assist members who struggle with homelessness. This department is called what?
Care Management!
300
Who is eligible for the 599 CHIP?
300
What is a Zero Balance Check?
Can mean no payment made on check run!
300
A member receives a $5,000 hospital bill and believes insurance “should have covered it.” How can you assist this member?
Lead with Empathy
Avoid jumping straight into deductibles or policy language.
Effective Opening:
“I can understand how receiving a $5,000 bill would be really concerning. Let’s take a look at the claim together so we can see exactly what happened.”
This reassures the member that you’re partnering with them.
Verify & Review the Claim
Confirm:
Date of service
Provider name
Type of service (ER, surgery, inpatient stay, etc.)
Whether claim has processed
Whether this is a bill or an Explanation of Benefits (EOB)
Then review:
Total billed amount
Allowed amount
Plan payment
300
Name a Centene Value!
Accountability
Courage
Curiosity
Trust
Service
Double points
300
How old do you have to be to join the Kids Club?
The club is mainly for kids 12 and under!!
Welcome to the Kids Club! We are a fun group of friends working together to get healthy. We try to stay active, eat healthy foods and snacks and help others. I am so happy you’re joining my club. (The club is mainly for kids 12 and under.) Are you ready to get healthy? Let’s have some fun.
400
What is NOT covered under 599 Chip?
Postpartum care, medical issues unrelated to the pregnancy, and services not provided to the newborn child are not convered.
400
If Medicare denies will we be considered as primary?
We would process as primary if Medicare denies, we need to Medicare EOP showing they denied.
400
A member with chronic pain is told their referral wasn’t approved. What can WE do?
Lead with Compassion
Avoid: “The referral was denied due to lack of medical necessity.”
Instead: “I’m really sorry you’re dealing with ongoing pain, and I understand how frustrating it must feel to hear that a referral wasn’t approved. Let’s review what happened and talk through your options.”
Acknowledge both the physical and emotional impact.
✅ Step 2: Clarify the Referral Status
Determine:
Was it denied, pended, or redirected?
What was the stated reason?
Missing documentation
Not medically necessary
Out-of-network provider
Step therapy requirement
No prior authorization
Confirm:
Referring provider
Specialist name
Service requested
Clinical review notes (if available)
✅ Step 3: Explain the Decision Clearly (Without Sounding Cold)
Translate medical review language into plain language.
Example:
“The review notes indicate that additional conservative treatments, like physical therapy, are typically required before a specialist visit is approved under this plan.”
Avoid implying the member’s pain isn’t valid.
✅ Step 4: Provide Immediate Next Steps
Never leave the member feeling stuck.
🔹 If Documentation Missing
Offer to contact provider’s office
Explain what’s needed
Give timeframe for re-review
🔹 If Medical Necessity Denial
Explain appeal process clearly
Provide deadline and submission method
Offer to send appeal form
Mention expedited review if condition is worsening
🔹 If Step Therapy Requirement
Clarify what must be completed first
Offer to check if prior treatments already qualify
🔹 If Out-of-Network Issue
Offer in-network alternatives
Verify network accuracy
Escalate if directory discrepancy exists
400
Who is the CPO
(Chief People Officer)
400
What is the resource called that members can use to see if something is covered?
The Benefits Grid on the NTC Website!
500
How do you verify HIPAA 599 Chip on a call?
500
True or False: We take care of provider dental grievances.
FALSE:
Provider dental Grievances will be TRANSFERRED to Centene Dental Services for assistance.
500
A member calls because their insulin or cancer medication was denied due to prior authorization requirements. They are crying and say, “Are you trying to kill me?”
What does the agent do in this situation?
✅ Step 1: Respond to the Emotion — Not the Accusation
Do not defend the company first.
Do not say “That’s just policy.”
Instead:
“I’m so sorry this is happening. I can hear how scared and overwhelmed you feel right now. Let’s work on this together.”
Acknowledge fear. Validate urgency.
✅ Step 2: Assess Immediate Risk
Gently clarify:
Are they currently out of medication?
How many doses remain?
Is this insulin needed daily?
Is cancer treatment already scheduled?
If they indicate immediate medical danger:
Encourage contacting their provider immediately
If symptoms are severe, advise emergency care
Example:
“If you are without insulin right now or feeling unwell, please contact your doctor immediately or seek urgent care while we work on this.”
(Stay within your role — do not provide clinical advice beyond safety direction.)
✅ Step 3: Explain Prior Authorization in Human Terms
Avoid:
“The medication requires prior authorization under your plan.”
Instead:
“This medication needs approval from your doctor before we can cover it. That doesn’t mean it won’t be covered — it just means we need some additional information from your provider.”
Important: Clarify that this is a process requirement, not a rejection of their care.
✅ Step 4: Identify the Status
Determine:
Was it denied or pended?
Has the provider submitted clinical information?
Is this first request or renewal?
Was it denied for step therapy or formulary issue?
Is there an alternative covered medication?
✅ Step 5: Offer Immediate Action Steps
Depending on situation:
🔹 If Provider Has NOT Submitted PA
Offer to contact provider’s office
Explain exactly what is needed
Mark request as urgent if allowed
🔹 If Denied
Explain appeal process clearly
Mention expedited appeal option for urgent medical need
Provide timeline (e.g., 24–72 hours for expedited review if applicable)
🔹 If Alternative Covered Medication Exists
Offer to review covered options
Suggest provider discuss substitution if clinically appropriate
500
Who are the people listed for Women's History Month?
500
This system is used when we cannot locate a provider in OMNI, what is it called?
NPPES NPI REGISTRY!!