Plan Benefits
What would we use to quote/find a MBR's copay for an MRI?
DEBUT
True or False:
If a member calls in and has codes for us, we can look those up for the member?
False! We can never check codes for a member.
Can we change a PCP that's OON?
No
What 2 systems can be used to update demographics?
1. CRM
2. CI
True or False:
Once verbal consent is obtained on a call, it is good for every call going forward if noted.
FALSE
Where would we look in DEBUT to quote a member their copay for injections?
Surgery Services
True or False:
A PPO plan requires a referral for all services.
False
What system is used to verify if a PCP is INN?
Physican Finder Plus (PFP) & PAAG (if needed)
After how many days do we need to verify an address on file?
90 days.
What pieces of information are needed when obtaining verbal consent from a member?
1. Name
2. DOB
3. Zip Code
4. Consent to speak to the person calling (if not on file)
If a member calls wanting their benefits for a 3D Mammogram. Would this be under standard mammogram or advanced imaging?
Standard Mammogram
How long is the typical turnaround time for an authorization, if not expedited.
7-14 business days
What Classification & Intent is used when research is needed for updating PCP?
PCP Research Requested
What are the 8 types of demographic changes?
Name, Address, Phone number, Email, Medicare ID, DOD (date of death), DOB (date of birth), Gender
Consent form expiration date, is it the same for all states?
No.
Some states have a 12month expiration, others have 24month expiration. Verify in Consent Methods Overview mentor.
True or False:
An ultrasound is found and quoted under basic radiology.
True
A member is calling to check the status of an authorization or referral. What would you use for your classification and intent?
Classification: Auth/Referral
Intent: Authorization or Referral
What 3 systems are used to update a PCP on file?
1. CRM
2. DIGBOT
3. CI
Tyler is calling to make a temporary address change. You see he has a PPO plan; how long can Tyler be Out of the Service Area (OSA)?
For PPO & PDP members, they can be temporarily OSA for up to 12months.
Refer to Temporary Address Change Calls for Medicare Members Mentor.
Are all POA types able to do the same thing?
No. POA Type O, Type H, Type U, and Type C are all for different things.
Refer to POA Types and Allowed Actions Mentor.
A member calls in and they are checking their transportation benefits. You see they have 24 one-way trips. How would you relay this message to them to break down round trips?
Advised the member that they have 24 one-way trips or 12 round trips.
What are the 3 types of authorizations. 100 bonus points if you can tell me what each mean.
What template in CRM do you fill out immediately after updating a PCP on file?
PCP Questions Template.
This is located on the right side of CRM once you associate your case.
Scenario:
Mukesha moved from Kentucky to Texas, you have already updated the address. What would you do next?
Warm transfer to DMS sales department to get Mukesha a new plan in Texas.
Members daughter is calling on behalf of her mother who passed last week. Nothing is on file, are we allowed to release information?
No.
For deceased members, we have to have Executor of Estate (EOE) on file before releasing ANY information. Refer to Power of Attorney and Executor of Estate Overview Mentor.