Wave 1
What are the call types in Wave 1 in which you as a Tier 1 advocate can't handle?
Grievance and Appeal Processes
Coordination of Benefit Processes
Misrouted Call
Billing Issue Processes
Resolving LEP Issues
(ETC)
What is the name of the resource that we have to help members who needs assistance for transportation, rent, etc.?
Humana Community Navigator
What is the name of the process in which we send the script of the prescriber to another supplier or pharmacy?
Prescription Transfer
Who decides what is inside Humana's Formulary List?
FDA
CMS
Humana
What is the name of the department who handles LEP Reconsideration Calls? and how many days does it take for this department to fix LEP issues?
- C2C Innovative Solutions Inc.
- 90 Days
What is the name of the vendors who decides if a preauthorization is approved?
Cohere Health
Evolent
Humana CIT
What is the name of the process in which the doctor provides permission to the patient to get medications that are not on the drug list?
Formulary Exception Request ~ prior authorization
What is the CI Command that you use to check other insurance information on CI?
PEOC
What is the name of the department who handles Grievance and Appeal issues? And how long does it take for this department to fix G&A issues?
Grievance and Appeal team
90 Days
What is the name of the negotiated amount approved by Humana, CMS and the provider?
Total Allowable Amount
What is the TAT for expedited and standard prior authorization?
Expedited - 24 hours
Standard - 48-72 hrs
What is the process that you will do if a member would like to transfer the prescription over to a pharmacy that is out of service area?
prescription transfer
How do you sign in on Customer Interface and go to the screen where you can process ID card requests?
- go/hod ~ Open CI on DIG BOT ~ Ci/PAPI Link on CRM
- Run the application
- CLS
- Sign In using your credentials
- Type "S" on the blank part that says DDE
- Type 1 and press enter
- Type C2MN on command
- Type UMID on command
- Paste the member's UMID on the UMID part
- press function 4 or F4
- Type PAPI on command
- select the plan
- Type PAID on command
- Type MR on reason section indicating member is requesting
- Press function 2 or F2
How many days is the TAT for expedited preauthorization and standard preauthorization?
Expedited - 48-72 hours
Standard - 7-14 calendar days
What is the name of the organization that can assist members to get samples just in case their medication is stolen, damaged or lost?
What is the name of the limit of expenses that a member can spend to have Humana cover the services for the member?
Maximum out of pocket
If a member assigns SSA as their method of payment, how many months does the member has to pay in a different account to avoid having past due balance on the account?
4 Months
What are the name of the benefits that are additionally added to MA plans to offer additional benefits to satisfy our members?
OSB
MSB
FSB
VAIS
(etc)
What is the name of the mentor document that you use if the provider is calling to ask for PCN and BIN number and Debut is not working?
Pharmacy Claims Overview
What is the exact process when you have a HEDIS annual checkup alert, but the member does not have a PCP on file and she has an HMO plan?
- Check if the member has the transportation benefit and if they do, ask if they would like to use it.
- Find a PCP on physician finder and assign someone based on the member's preferences
- Since they have an HMO plan advise the member that they will receive a new Humana ID Card on their current mailing address
- Let the member verify the mailing address on file, in case if the member has a new mailing address, process the update plan demographic template and add the new mailing address
- Call the new pcp on file to set up an appointment
- Before transferring ask the member if they would like you to stay on the line