Duals
A dual eligible member is considered is deeming status if they lose what kind of eligibility?
A. Medicare
B. Medicaid
C. Both Medicaid and Medicare
D. None of the above
B
Member calls in to check the status of their claim, what would be your C/I ?
Claims/Status
What screen in CI do you use to locate a members Medicaid information?
MEVH
What program or tool in CRM would you use to help process a premium payment for a member?
E-billing
What is you opening statement?
Thank you for calling humana. My name is ______, your health care advocate. How may I help you?
How long does the member have to regain medicaid eligibility while they are in the deeming period?
6 months
Member calls in to see if there has been a claim process for a certain DOS, what quick link in CRM would you choose to pull up claim history for this member?
Claim Summary link on the plan member page
Verification of Chronic conditions form OR VCC form.
Where would you find out if the member is part of the part B premium giveback program?
Under the Cost and deductibles link in debut
Member needs to be transferred to another department, when would you do your recap and closing statement?
before transferring member to the other department.
Where is the Dual Status 12-Mo Flag located in CRM?
Plan Member page
Claim denied due to not having an approved referral on file. What mentor process would you follow?
Claim penalty or Denial for No Preauthorization or Referral Calls.
Member called in to see if we received the VCC form from their provider. What screen in CI would you use to see if the form was received?
CSNP screen
Member called into determine if an authorization is needed for an MRI. What tool would you use to determine if a preauthorization is required?
Preauthorization and Notification List (PAL list)
What 3 elements do we need to get in order to authenticate the member?
Member id/Medicare ID
DOB
Zipcode
When verifying benefits what are 2 eligibility status criteria that should be confirmed?
A. Dual Eligibility & Cost share protection status
B. Traditional Medicare Status and Low-Income Status
C. Provider Credentials & Service Rendered
D. Nothing
A
What Screen in CAS would you use to display a referral that was sent in from the members PCP?
RFI
What screen in CAS would you use to review members benefit Accumulations?
MAI
Members plan is set to term at the end of the month. You located the term code of "107" Why is the members plan terming? and where did you locate the term code in CRM?
Member is enrolled in a non-humana plan, term code is located on the plan member page under the plan tab
When is AEP (open enrollment period)?
October 15th to December 7th
What does it mean to be Cost Share protected?
Cost-share protection refers to the amounts the member isn't responsible for when using their benefits
What is the control line for the MHI screen?
MHI,Member ID,Suffix (if applicable),First Name,Relationship,Claim Number (optional)
What are the three reasons that a payment on a claim was recouped?
hint: answer is in mentor :)
1. A claim payment has already been issued
2. An investigation determines that the payment, or part of the payment, should not have been made.
3. Recovery of the overpayment is required through a full and partial repayment process.
Member called in to update her other insurance information. Where would the Other insurance template be located?
under processes on the case edit page.
What mentor document should you look at daily during mentor time for any process updates, and/or communications for known issues?
Medicare Hot topics