claim
pharmacy
hipaa
navigation
support
100

WHERE DO YOU FIND IF THE CLAIM IS INN / OON PROVIDER? 

CLAIMS >> SYNOPSIS 

100
HOW DO YOU GET TO THE PHARMACY PAGE? 

SELECT OPTUMRX >> PHARMACY >> RX BENEFITS 

100

IF A CALLER CALLS IN AND IS NOT ON THE PLAN - HOW DO WE DOCUMENT? 

ORIGINATOR TYPE: OTHER 

DOCUMENT C/B AND NAME / GROUP 

100

HOW CAN YOU FIND INN PROVIDERS AND SUGGEST THEM TO THE MEMBER? 

ISET >> PROVIDERS >> SEARCH BY TYPE OF PROVIDER / ZIP CODE - THEN FILTER BY POS (OFFER TO SEND EMAIL / TEXT) 

100

WHICH TEAM WOULD YOU CALL FOR ASSISTANCE WITH OPTUMRX? 

OPTUMRX ASSIST 

200

WHERE CAN YOU FIND HOW MUCH A SPECIFIC CLAIM APPLIED TO DEDUCTIBLE? 

CLAIM >> SYNOPSIS >> DEDUCTIBLE 

200

WHAT DO WE DO IF THE MEMBER DOESN'T HAVE OPTUMRX? 

WARM TRANSFER TO PBM 

200

WHAT ARE THE THREE ITEMS YOU NEED TO CHECK FOR HIPAA? 

MEMBER ID

NAME 

DOB 

ADDRESS ON FILE 

200
WHAT HAPPENS WHEN YOU HAVE AN INCOMING CALL FOR SOMEONE WHO'S ON A DEDICATED TEAM? 

WARM TRANSFER TO APPROPRIATE TEAM 

200

WHO ARE IN THE CHAT WHO WOULD BE ABLE TO ASSIST? 

OJT / SPE'S / TEAM / LEADERSHIP

300

WHERE WOULD YOU FIND THE INFORMATION FOR DIAGNOSIS CODES? 

CLAIMS >> SUMMARY 
300
RXCLAIMS: WHERE DO YOU FIND THE REJECT CODE? 

PROCESSING > REJECT CODE 

300

IF THERE IS NO ARF / POA ON FILE, CAN YOU STILL SPEAK TO A CALLER CALLING ON BEHALF OF SOMEONE ELSE? 

YES- BUT ONLY GENERAL INFORMATION 

300

HOW DO YOU FIND WHAT TO DO WHEN THERE'S AN OUTAGE? 

E&I TOOLKIT >> BUILDING TRUST THROUGH ADVOCACY >> SYSTEM / OUTAGE 

300

WHAT IS THE NAME OF THE AI THAT HELPS US IN ISET? 

AVA


400

WHAT IS THE DIFFERENCE BETWEEN CPT / HCPCS AND DIAGNOSIS (DX) CODES? 

CPT / HCPC - BILLING / PROCEDURE CODE 

DIAGNOSIS - WHY / REASON FOR MEMBER HAVING THIS DONE

400
RX DEDUCTIBLE MAY BE DIFFERENT FROM MEDICAL, TRUE OR FALSE?

FALSE - DEPENDS ON THE PLAN. (CAN CHECK PHARMACY >> RXDED / OOP / MAX ACCUMULATORS) 

400

WHAT IS PHI? 

PROTECTED HEALTH INFORMATION 

Policy

  • When using or disclosing PHI or requesting PHI from another entity, make every effort to limit the PHI to the minimum necessary needed to accomplish the task.
  • Operations will limit access to and disclosure of PHI as required by law. It is Operations' policy that all employees will preserve consumer, physician, and other provider confidentiality.
  • Strict adherence to this policy is needed to protect the confidentiality of PHI from improper or illegal disclosure and to ensure compliance with applicable federal and state confidentiality and privacy laws, as well as UnitedHealth Group's corporate policies governing the confidentiality of health information.
400

WHERE DO YOU FIND THE DME NATIONAL ANCILLARY LIST? 

National DME Providers - National DME Provider Listing - All Items (sharepoint.com) 



400

WHERE CAN YOU LOCATE IBAAG? 

AVA 

500

WHAT IS THE "MEAT AND POTATOES" TAB OF CLAIMS? 

CLAIMS >> SERVICE LINES 

500

HOW CAN YOU FIND OUT HOW MUCH A MEDICATION IS FOR THE MEMBER? 

EITHER PRICING TOOL / TIERS CHART (RX BENEFITS) 


500

WHAT HAPPENS WITH MEDIA CALLS? 

Note: Follow this process if a caller is from the media or the caller states they have contacted the media.

  • Agent should not service this call; a supervisor needs to handle the next steps.
  • Immediately notify supervisor of the issue.
  • Advise the caller we will connect them with a supervisor for assistance.
  • Document and Route.
500

WHAT'S THE FIRST THING YOU DO WHEN SOMEONE ASKS TO ENROLL IN PHARMACY MAIL SERVICE? 

OFFER TO HELP THEM SIGN UP ON MYUHC.COM

500

WHAT IS THE SOURCE OF TRUTH FOR SOP'S? 

E&I TOOLKIT 

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