Golden Hour

Turnaround times

100

What is the turnaround time for a claim to be reworked?

Most claim rework reviews are completed in about 30 days from the date of the request. Members will receive a new EOB after reprocessing approximately 60 days from the date of the request. However, reprocessing can take up to 60 days in some cases.

200

When are we able to view a fax submission?

• Received faxes will be viewable on the Fax Central Web Site within 10 minutes of receipt.

  
  

  Received faxes will appear in ECHS or EWM within 24-48 hours.

  
  

• Standard shipping: 8 to 10 days from request date, or 5 to 7 business days from the date of mailing (shown in GPS once created) and the card will arrive in a purple envelope

300

What is the turnaround time for a stop pay and reissue?

It can take up to 30 to 45 days for the request to be processed and another 7 to 14 days to be received by the member. 

400

What is the timeframe to file a grievance?

Grievance’s must be filed within 60 days from the date of the incident.

500

How long does it take for a cob to be updated on a members including the rework process?

Most COB updates are completed within 15 business days 

The rework can take up to 45 days. (Total turnaround time is 60 days from the date of the request

Systems

100

What system is used to verify a members demographic information?

MARX

200

What system is used to view case notes from a members care team?

Medcompass

300

Which system is used to verify claims payment details?

HRP

400

This system is used to file an expedited appeal and grievance?

Stars

500

Using rumba, if a members net id is 3222. Is provider John Choy in network at 

3420 Fruitville Rd

Sarasota,FL 34237

YES 

Call handling and documentation

100

When should the outbound feature in GPS be used?

 anytime you're reaching out to the contact for more info by making an outbound call, sending an email, correspondence, fax, or form outside the company.

200

What information should not be included in your documentation?

Credit/debit card numbers.

Checking or saving account numbers

 MBI, Medicaid, or social security number.

Emojis and slang do not belong in documentation and should never be used in any case comments.

300

What are the different types of hold procedures when placing a member on hold? And what are the time frames?

Silent hold-1-2 minutes

Standard hold-3-5 minutes

Dead air-45 seconds

400

What information is needed to document a call?

• Document the reason for the call.
• Document all actions that were taken by you on the call.
• Any follow-up actions needed and why.
• What information did you provide to the member/caller.
• This should be a summary of who, what, when, where, and why.
• Member/Caller expectations are applicable.
• If they use foul language, document as callers used foul or explicit language. It is not necessary to put in the actual language used.
• Document the employee’s first name and A# or N#. 

500

How is a call handled if a member request their id number over the phone?

Can provide you with the MBI/HICN number

You can supply the member ID# to them

Cannot provide you with the MBI/HICN number

• you can send a new ID card to you or
• they can obtain the member ID number via the secured member portal.
• For security purposes, I cannot supply your Aetna Medicare ID over the phone at this time.

General Member and Provider Support Knowledge

100

True or False

A member calls to cancel their enrollment after the effective date. This request can be done verbally

False; a cancellation after the effective date would need to be in writing, they must have a valid election period, and it must be signed by the member or the Authorized Representative.

 

200

What type of liberty dental calls are handled by Medicare csrs?

Member Dental Complaints and Appeals 

Enrollment 

Evidence of Coverages (EOCs)

Explanation of Benefits (EOBs)

ID Cards

Medical Benefits

Medical Claims

Medical Provider

Premium /Billing

300

What are 2 situations in which a member can file an expedited grievance?

• The member disagrees with our refusal to grant a member’s request for an expedited organization determination or an expedited appeal.
• The member disagrees with our decision regarding an extension relating to an organization determination, or an appeal

400

WHAT ARE SOME EXAMPLES OF PROVIDER CALLS THAT WE HANDLE? AND WHAT IS AN EXAMPLE OF A MISDIRECTED PROVIDER CALL?

PER KA 3678;A provider calls to request an expedited grievance on behalf of a member.

 The provider is calling on behalf of a member to file an expedited appeal or check the status of an expedited appeal.

These calls are for Pre-Service issues and are not handled by Provider Services. 

If provider is calling for anything other than an expedited appeal 

500

Under what circumstances are we able to give out claim/preauthorization/precertification information to someone other than the member?

If the requester has some prior knowledge:

• The requester can prove they know something about the claim/preauthorization/precertification in question
• The requester can give some details about the service done or requested and the approximate date of service and/or the provider's name

Enrollment Periods

100

What are the enrollment periods?

IEP

AEP

OEP

SEP

200

What is a Service area reduction?

Service Area Reduction (SAR) occurs when a Medicare Advantage (Part C) or Prescription Drug Plan (Part D) plan reduces the geographic area it serves. This means that some counties previously covered by the plan will no longer be included.

300

What is a non renewal?

Non-Renewal (NR) occurs when a Medicare plan (Medicare Advantage or Part D) chooses not to renew its contract with Medicare for the upcoming year.

This means the entire plan will no longer be available to anyone, regardless of their location.

400

What ka would be used to assist a member with disenrolling from their plan?

KA 2584;Members can only disenroll after the effective date of the plan unless they are part of the OEV Process 

500

What are some common SEP's?

Gaining or losing creditable coverage

Moving in or out of a plan service area

Moving in or out of a nursing home

Joining a 5 star plan