Medi-Cal KBs
What is the KB for Medi-Cal Eligibility
KB 126858
Member is calling because they are in the emergency room and need treatment right away. Member needs confirmation they currently have active coverage with Health Net. Is an example of what type of eligibility?
Current Eligibility
If eligibility message in AEVS appears as follows:
Eligibility Message: NO RECORDED ELIGIBILITY FOR MM/YY or TERM.
What signal light will display in AEVS?
Red
What is the TAT for Standard Medical Authorization Request?
5 business days
It is a program that delivers specific services at an Outpatient center to qualifying individuals.
Community-Based Adult Services (CBAS)
What is the KB for Medi-cal HIPAA?
KB 29240
The member’s coverage is currently suspended. Typically, this happens when there is a discrepancy or member having a Share of Cost.
On Hold
When a member has a_________ , the eligibility message appears as follows:
Eligibility Message:
SUBSCRIBER LAST NAME: DOE. MEDI-CAL SUBSCRIBER HAS A $02323 SOC/SPEND DOWN. REMAINING SOC/SPEND DOWN $ 2323.00.
Share of Cost (SOC)
_________ is contracted with Health Net to provide authorization for sleep studies and radiation therapy for FFS members.
eviCore Healthcare
_________ program allows members to remain at home as an alternative to nursing facility placement.
Multi-Purpose Senior Services Program (MSSP)
What is the KB for Omni 2.0 Omni Intent Guide for SHP?
KB 126908
What eligibility sub-screen allows agent to search current, future or retro eligibility and provides eligibility disclaimers.
Eligibility Sub-Screen
If Eligibility message appears as follows:
Eligibility Message:
SUBSCRIBER LAST NAME: DOE. EVC #: 1111XX111111. CNTY CODE: 19. 1ST SPECIAL AID CODE: 8W. MEDI-CAL ELIGIBLE W/ NO SOCSPEND DOWN
What signal light color will display in AEVS?
Green
Services listed below will need authorization from?
Coronary computed tomography angiography (CCTA), Myocardial perfusion imaging (MPI),Multigated acquisition (MUGA) scan,Stress echocardiography
NIA
_______ is a State program that allows seniors and persons with disabilities to remain safely in their own home.
In-Home Supportive Services (IHSS)
What is the KB for AEVS?
KB 30657
The_________intent is used to generate a Proof of Eligibility form to be faxed to a provider.
Form Based Communication
If a member is found to be inactive with our plan in AEVS, but still active in OMNI, we have to request for disenrollment. Which workbasket the request needs to be routed?
CNC_MedicaidEnrollment_WB
Services listed below need authorization form?
Hip arthroplasty, Hip arthroscopy, Hip resurfacing, Ankle arthroplasty, Ankle fusion
TurningPoint
________ assist eligible beneficiaries to receive available services in their own home or community that are not a managed care benefit.
Home and Community-Based Services (HCBS)
The Healthcare Insurance Portability and Accountability Act (HIPAA) was signed into law in what year?
1996
What eligibility sub-screen allows the agent to get the PCP name, office of practice, office hours, office phone number and fax number as well as the office accessibility.
PCP Information sub screen
If the member’s PHP is showing Health Net/Calviva, document the caller using the Member Not Found flow, and route the details to the Membership Dept. Use the Internal Routing feature in the Log View Status intent and route to?
CNC_MedicaidEnrollment_WB.
________ ensures Health Net’s compliance with all state and federal rules and regulations. They handle all lawsuits and third-party liability.
Legal Affairs
_______ program covers the treatment and services related to the eligible medical conditions for children 0-21 years of age.
The California Children Services