Flags
Coverage Determination
QOC
MIOD/OD

Verbal Grievances
Call Categorization

SOP
100


Bangladesh

100

Member calling for a CD for the current plan year w/o expression of urgency.

What is a standard CD?

100

Has the potential to result in physical or mental harm, such as a worsened medical condition

Antarctic Blue Whale

DOUBLE JEOPARDY: DOUBLE POINTS

100

Standard OD plan must make a decision in this time frame.


What is 14 days?

100

Who, What, Where, When, Why, How

What are the documentation requirements?

100

Rude behavior,

Misinformation

Difficulty understanding

Advocate Interaction (Gyms, Nurse Line, Advocate Representative)

    


100

What Job Aid tells you who can submit an Organization

Determination

DOUBLE JEOPARDY: DOUBLE POINTS

SUBMITTING A COVERAGE DETERMINATION

200


Belgium

200

Prior Auth, Step Therapy, Quantity Limit


What are the reasons for filing a CD?

DOUBLE JEOPARDY: DOUBLE POINTS

200

Misdiagnosis

Delay in referral, treatment or diagnosis

Complications and/or factors contributing to death.

Australia

200

This OD must be completed no later than 30 days after the request is made.

What is a Post Service OD?

DOUBLE JEOPARDY: DOUBLE POINTS

200

Identify

Resolve

Document

Categorize

What are the tips used to successfully handle a grievance?

200

Member upset for wait time to reach a rep/advocate

Member upset about excessive transfers

Member upset about the time spent on the phone with the rep/advocate

     Complaint About (Transportation Vendor) Call Time/Hold Time/Transfers

200

Where would you locate the information that must be documented for all QOC issues?

SYSTEM DOCUMENTATION-APPEALS, GRIEVANCES, CDs & Ods

300


Australia

300

Application used to check for existing CDs and create new ones.

What is PAS?

300

Name of the QIO Org

QIO Address

QIO Website

QIO Phone/fax #s

?

Sheep

300

    




What 2 instances do we not use the MIOD form but warm transfer?

300

Complaints about medical services, doctors, facilities, etc.

What services are coded under medical Part C?

300

Broker gave incorrect information when enrolling them into the plan

Broker enrolled the member into the plan without their knowledge or consent

Broker/Agent rude

Sales Agent/Broker Fraud, Misrepresentation or Behavior

300

What Job Aid would assist an advocate if a member is expressing dissatisfaction with a specific Pharmacy?

GRIEVANCE HANDLING-PART C vs PART D & FAQ

400


Spain

400

natural disaster, dosage change, 

What are the reasons for an override?

400

Name of prov/fac/hosp/pharm

Person-1st & last name

Address of prov/fac/hosp/pharm

House Calls & Transportation- where member needs to go and contact # of the party he needs to see

Contact- phone number

Etc.………….

AB negative

400

I-CUE

Where to look for MIOD, OD, AND PA request?

400

“I received a bill”

“Please stop with all the calls”

“Transportation was late picking me up, but I made it to my appointment”

“The receptionist in the doctor’s office was rude”

What are examples of why a Standard Grievance would be filed?

400

Outbound campaign/promotional calls

Outbound campaign/promotional mailings (brochures, advertising, commercials, emails)

Excessive Calls and Mail from Plan or Plan Vendors

400

What Job Aid tells you how long after receiving a Notice of Denial does a member have to submit an appeal?

COVERAGE DETERMINATION STATUS > PRIOR AUTHORIZATION DENIAL

500


Haiti


500


Jackie Chan

500

This essential gas is important so that we can breath

Oxygen

500

Non-covered benefit

Benefit Limit/Allowance

Network Gap Exception

CoC/ToC

What are examples a MIOD would be filed?

500

When do girrafe have 8 feet

When there is 2 of them

500

Does not like or never requested automatic refills

Billed credit card without authorization

Requires certain approvals for prescription services

Complaint About Optum Rx Operations/Polices

DOUBLE JEOPARDY: DOUBLE POINTS

500

This Job Aid tells you what time zone should be used when filing a MIOD?

DOUBLE JEOPARDY: DOUBLE POINTS SUBMITTING MIOD REQUEST

600

Panama

600


James Brown

600

When you make light change direction by passing it through a lens.

What is refraction.

DOUBLE JEOPARDY: DOUBLE POINTS

600

A request to pay for or authorize a service to which the member believes he/she is entitled.

What is the PA process/what is an OD?

600

What can you hear but not touch or see and yet control?

your voice

600

Member received a call from someone claiming to be from UHC.

Suspicious Phone Calls

600

What Job Aid has 2 options for documenting Provider Info on Transportation QOC issues?

GRIEVANCE HANDLING

700


Double Jeopardy: Double Points

New Zealand

700


DOUBLE JEOPARDY: DOUBLE POINTS

Fidel Castro

700

The amount of elements on the periodic table.


118

700

Plan must make a decision in 72 hours.

What is an expedited OD?

DOUBLE JEOPARDY: DOUBLE POINTS

700

You are my brother, but I am not your brother. Who am I?

I am your sister.

DOUBLE JEOPARDY: DOUBLE POINTS

700

PCP refused to refer a specialist

Provider will not submit referral

Referral not received by specialist

Missing documentation needed

Unable to Receive Referral

700

What Job Aid would assist an advocate in attaching a note to a request in the PAS?

FILLING OUT A COVERAGE DETERMINATION REQUEST FORM – ATTACH A NOTE

800


India

800


Tony Blair

800

Who was the first man to walk on the moon?

Neil Armstrong

800

A specific dental benefit or service

 ( e.g. extraction, crown, cleaning).


What can a member submit an OD request for regarding Dental?

800

Say my name I dissappear.

Silence

800

Member unable to login to account

Website down

Unable to download/print forms

Difficult to navigate

Plan Web/Internet/Email

800

The member is going to see Dr. Jones and transportation does not pick him/her up. The member did complete their visit. Which Job Aid identifies what type of grievance this is?

GRIEVANCE HANDLING – QOC IDENTIFICATION

900


Russia

900


Maureen O'Hara

900

The planet that completes its rotation the fastest in just 10 hours.

What is Jupiter.

900

 This is a decision about Part C payment or benefits made prior to the effective date of a member's plan.

What is a MIOD - Advanced Requests (AEP)?

900

Poor people have it. Rich people need it. If you eat it you die. what is it?

Nothing

900

Note: Select this option if the member’s grievance has been identified as a QOC grievance.

Inadequate Care (QOC)


DOUBLE JEOPARDY: DOUBLE POINTS

900

Which Job Aid would you go to and see if a member has an approved Coverage Determination?

SUBMITTING A COVERAGE DETERMINATION REQUEST

1000

Double Jeopardy: Double Points

Afghanistan

1000


Stompin' Tom Connors

1000

Fastest land animal?

Cheetah

1000

Info Path Form.

What form is used for a MIOD Change/Cancellation?

1000

When is it a bad time to see a black cat

When you are a mouse

DOUBLE JEOPARDY: DOUBLE POINTS

1000

Received someone else’s member material.

 Received Another Member’s Materials (PHI or HIPPA Breach)

1000

What Job Aid will assist you with the reason/sub reason the member is expressing dissatisfaction for not receiving a formulary after speaking with advocate 4 times?

GRIEVANCE CATEGORIZATION

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