Bangladesh
Member calling for a CD for the current plan year w/o expression of urgency.
What is a standard CD?
Has the potential to result in physical or mental harm, such as a worsened medical condition
Antarctic Blue Whale
DOUBLE JEOPARDY: DOUBLE POINTS
Standard OD plan must make a decision in this time frame.
What is 14 days?
Who, What, Where, When, Why, How
What are the documentation requirements?
Rude behavior,
Misinformation
Difficulty understanding
Advocate Interaction (Gyms, Nurse Line, Advocate Representative)
What Job Aid tells you who can submit an Organization
Determination
DOUBLE JEOPARDY: DOUBLE POINTS
SUBMITTING A COVERAGE DETERMINATION
Belgium
Prior Auth, Step Therapy, Quantity Limit
What are the reasons for filing a CD?
DOUBLE JEOPARDY: DOUBLE POINTS
Misdiagnosis
Delay in referral, treatment or diagnosis
Complications and/or factors contributing to death.
Australia
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
Identify
Resolve
Document
Categorize
What are the tips used to successfully handle a grievance?
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
Where would you locate the information that must be documented for all QOC issues?
SYSTEM DOCUMENTATION-APPEALS, GRIEVANCES, CDs & Ods
Australia
Application used to check for existing CDs and create new ones.
What is PAS?
Name of the QIO Org
QIO Address
QIO Website
QIO Phone/fax #s
?
Sheep
What 2 instances do we not use the MIOD form but warm transfer?
Complaints about medical services, doctors, facilities, etc.
What services are coded under medical Part C?
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
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
Spain
natural disaster, dosage change,
What are the reasons for an override?
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
I-CUE
Where to look for MIOD, OD, AND PA request?
“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?
Outbound campaign/promotional calls
Outbound campaign/promotional mailings (brochures, advertising, commercials, emails)
Excessive Calls and Mail from Plan or Plan Vendors
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
Haiti
Jackie Chan
This essential gas is important so that we can breath
Oxygen
Non-covered benefit
Benefit Limit/Allowance
Network Gap Exception
CoC/ToC
What are examples a MIOD would be filed?
When do girrafe have 8 feet
When there is 2 of them
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
This Job Aid tells you what time zone should be used when filing a MIOD?
DOUBLE JEOPARDY: DOUBLE POINTS SUBMITTING MIOD REQUEST
Panama
James Brown
When you make light change direction by passing it through a lens.
What is refraction.
DOUBLE JEOPARDY: DOUBLE POINTS
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?
What can you hear but not touch or see and yet control?
your voice
Member received a call from someone claiming to be from UHC.
Suspicious Phone Calls
What Job Aid has 2 options for documenting Provider Info on Transportation QOC issues?
GRIEVANCE HANDLING
Double Jeopardy: Double Points
New Zealand
DOUBLE JEOPARDY: DOUBLE POINTS
Fidel Castro
The amount of elements on the periodic table.
118
Plan must make a decision in 72 hours.
What is an expedited OD?
DOUBLE JEOPARDY: DOUBLE POINTS
You are my brother, but I am not your brother. Who am I?
I am your sister.
DOUBLE JEOPARDY: DOUBLE POINTS
PCP refused to refer a specialist
Provider will not submit referral
Referral not received by specialist
Missing documentation needed
Unable to Receive Referral
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
India
Tony Blair
Who was the first man to walk on the moon?
Neil Armstrong
A specific dental benefit or service
( e.g. extraction, crown, cleaning).
What can a member submit an OD request for regarding Dental?
Say my name I dissappear.
Silence
Member unable to login to account
Website down
Unable to download/print forms
Difficult to navigate
Plan Web/Internet/Email
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
Russia
Maureen O'Hara
The planet that completes its rotation the fastest in just 10 hours.
What is Jupiter.
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)?
Poor people have it. Rich people need it. If you eat it you die. what is it?
Nothing
Note: Select this option if the member’s grievance has been identified as a QOC grievance.
Inadequate Care (QOC)
DOUBLE JEOPARDY: DOUBLE POINTS
Which Job Aid would you go to and see if a member has an approved Coverage Determination?
SUBMITTING A COVERAGE DETERMINATION REQUEST
Double Jeopardy: Double Points
Afghanistan
Stompin' Tom Connors
Fastest land animal?
Cheetah
Info Path Form.
What form is used for a MIOD Change/Cancellation?
When is it a bad time to see a black cat
When you are a mouse
DOUBLE JEOPARDY: DOUBLE POINTS
Received someone else’s member material.
Received Another Member’s Materials (PHI or HIPPA Breach)
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