Organization Determination
Types of Coverage Determination
Systems Used
Turn Around Times
Scenarios
100
Any determination (Decision) made by the health plan with respect to any of the following : Payment for temporarily out of the area : Renal dialysis services Emergency services Post-stabilization care Urgently needed services.
What is a Organization Determination?
100
A request for a decision about whether to provide, pay or not pay for a medication because its not on the plans formulary.
What is Non- Formulary
100
what system do you use to look up medication or provide member with alternative options?
What is RXweb
100
What is the standard/ Expedited TAT for a Coverage Determination
What is 72 Hours after optum recives the fax from the Doctor 24 Hours after optum recives the fax from the Doctor
100
Member calls in stating they were told by the sales agent they would not have a premium for his plan,the member received a letter telling him his plan premium is $35.00. What type of grievance would you file?
Sales Grievance
200
A member or Physician may request to ________ an organization determination because they believe that waiting for a decision under the standard time frame may jeopardize the member’s life, health, or ability to regain maximum function.
What is Expedite
200
A tier cost sharing decision when the member thinks its too high.
What is tier exception
200
What system is used to document coverage determinations
What is MIIM
200
what is the standard/ expedited TAT for a Pre- service organization determination
What is 14 calendar days 72 Hours
200
!!!!!DOUBLE JEOPARDY!!!!!!! Member calls in stating "I went to my DR when I was having a bad cough when I went in he didnt exam me but told me to go home and get some rest. Later that night I felt worse so I went to the ER, they told me I have pneumonia. What type of grievance would you file for this member? What information must be givin with this comaplaint.
Quality Of Care, Members QIO (Quality Improvement Organization) Rights
300
!!!!!DOUBLE JEOPARDY!!!!!!! When the member is requesting a specific provider/facility. After answering yes to the question in MIIM please make sure to document the...
What is Doctor/ Facility Name, Phone number and address
300
A request for a decision about whether to provide or pay for a medication because the drugs is exlcuded and the member believes should be covered byt the plan.
What is CMS Excluded
300
What system do you use to verify if a coverage determination has been submitted, or is pending/ denied.
What is RXclaims
300
How long will optum wait for the Doctors response on a standard coverage determination request?
What is 10 days
300
Member called in stating she went to her DR's appointment on Monday, however when she was in the patient waiting room the paper sheet on the bed had brown and yellow stains and looked sweaty, the member stated when she told the nurse she got an attitude and ripped the paper sheet off and told her to stop being so picky. What type of grievance(s) would you file
2 Quality of Service Complaints
400
the name of the Capitated/ Delegated group
What is wellmed
400
A decision whether a member has, or has not, satisfied a prior authorization or other utilization management requirement.
What is Prior Authorizations (PA) Or Utilization Management (UM) Review
400
What system is used to verify if a DR/ Facility has submitted a organization determination on behalf of the member?
What is ICUE
400
How long will optum wait for the Doctors response on a expedited coverage determination request
What is 4 days
400
Member called in stating "I have called twice and keep getting disconnected with customer servcie and the reps dont call me back? What type of grievance woudl you file
Standard
500
If the members plan is delegated who must we contact to complete the member request
What is the members PCP/ Provider
500
What is the difference between non- formulary and medicare excluded?
What is Non- formulary is when the plan does not cover the medication and its not on the formulary CMS Excluded is when the medication is considered a Part D ecluded drug. (the drug is not on medicare's approved list)
500
What is the name of the syatem used to check prior authorizations for Dual members
What is CareOne
500
What statement has to be documented when submitted an expedited request for any A&G?
What is Member/ Caller believes that waiting the standard timeframe may jeopardize the member’s life, health, or ability to regain maximum function due to...
500
Member called in stating "Optum Has charged the wrong amount to his credit card" what type of grievance would you file, and does it require follow up.
RX/ Part D Grievance, Yes Follow up is required
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