INFORMATION 101
Information needed in looking for a claim (3)
account number
provider's name/facility's name
date of service
amount of the bill
type of service
A tool used in locating stores wherein member can go using their OTC benefits
Store Finder (healthybenefitsplus.com)
What to provide to the member if member needs to purchase OTC but member has no physical card?
* Card number
* Security Code
True or False: A new email address cannot be added without the member’s verbal consent.
True (Ref KM1007997)
Intent used if member is requesting a comprehensive formulary list
Member materials
Information needed in scheduling a transportation appointment (5)
* Nature of appointment
* date and time of the appointment
* member's active phone number
* pick up address
* facility name/doctor's name
* facility's phone number/doctor's phone number
* mobility type (needs assistance)
* facility's address (destination)
* pick up time
* ride ID numbers
For DSNP member's what is their order of COB?
Primary - Medicare
Secondary - Medicaid
A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.
HIPAA
States will notify members they have a Call to Action by sending a renewal packet within __ days of the expected renewal date.
45-60 days
Information needed in using DSNP Toolbox to pullup plan information
State and contract number
Used in finding extra help to the member if member's Medicare and Medicaid benefits are all exhausted
findhelp.org by findhelp - Search and Connect to Social Care
A set time each fall when Medicare Advantage (MA) AND Medicare prescription drug coverage Members can change their health or drug plans or switch to Original Medicare.
Annual Election Period (AEP)
Examples of Caller Types
Member
Authorized Representative
POA/ Guardian / Conservator
Trustee
Attorney
Broker
Employer Group
Foster Parent (C&S Only)
Insurance Company
Internal Caller
Media Representative
Parent / Guardian of a Minor
Provider
SHIP Counselor
Third Party- Others
Federal / State Regulator (SPAP, CMS, State Medicaid Agency
Member's personal advocates
Navigators
If member did not receive his/her U-card and needs to refill his/her prescription medication, what are the information that should be provided to the member?
* group number
* master group number
* contract number
* PBP and segment number
* RXBin, PCN and RX Group
A tool used to check and view the status of HRAs and RSAs. Locate information regarding medical prior authorizations.
ICUE
Refer to Non-Contracted Provider
OON (Out of Network)
True or False: If the caller is a broker, member does not need to be present to provide permission; the broker only needs to verbally attest that they have received permission from the member.
True (Ref KM1004106)
Gaps in care
Next Best Action (NBA)
Information needed in locating a member
* member ID
* Full Name
* DOB
* address
A tool used in checking member's Medicare Health Plans, their benefits and their coverage.
UnitedHealthcare Community Plan (uhc.com)
A department within the Plan responsible for answering questions about membership, benefits, grievances, and appeals.
Customer Service
True or False: We are allowed to disclose general information about the member's account if the caller is not the member
True
Information needed in using DSNP Toolbox to pullup plan information
State & Contract number