Acronyms
What does PCP stand for?
Primary Care Physician
When creating a Pest Control authorization what is the diagnosis code that is entered?
R68.89 (Other general symptoms and signs)
What is the copay and deductible responsibility for members under the STAR Program?
Copay and deductible does not apply to Medicaid STAR
What is the name for the Texas pharmacy carrier?
Carelon RX
For an initial Case Management/Social Worker referral, what is the TAT that is advised to the caller for the CM department to follow up?
5 business days.
Note: Refer to CTD pg. 12 section 4c
What does DMO stand for?
Dental Management Organizations
What types of residences is pest control service not covered? Please provide at least two examples.
Assisted Living (ALF)/Residential Care or Adult Foster Care settings, PCH (Personal Care Home), apartment complexes, or institutions.
True or False: Dual or Non-Dual STAR Kids members that only receive SSI are enrolled in a state waiver program.
False: Plan product reflecting Dual or Non-Dual STAR Kids receive SSI and are NOT enrolled in a state waiver program.
Note: Refer to CTD pg. 47
If member calls stating, they have lost their medication. Where should the OCS transfer the call to?
Carleon TX Technical help desk # 1-844-367-6114
What does FFS stand for?
What is FFS?
Fee-for-Service
Traditional Medicaid and will be disenrolled from MCO.
ABC Therapy calls and states the provider's name on the PT authorization is incorrect. Upon investigation, you notice the error was made by our pre-cert team. What steps should we take to assist the provider?
If the auth error entry is on behalf of the Pre-cert Team, email the corresponding Pre-cert TL & cc all OCS Managers for follow-up. (In this case Mgr. Paige McNamara & TL Daniel Carmon)
Note: Refer to CTD pg. 40 Pre-cert/DME Call Workflow hyperlink.
What is a service that does not require a referral but will need a pre-approval?
**Bonus Question for 100 points**
Name at least 2 services that do require a referral.
Behavioral Health Facility
PT/OT/ST, Specialists
For providers/pharmacy requesting authorization or status on Medical injectables (J codes/Q codes). Where should the call be warm transferred to?
pharmacy internal ext. 999-888-2214 or 1-844-367-6115
What are three crisis situations that would require transferring a call to the Behavioral Health Team?
Intent, threat, or plan to harm him or herself/Intent, danger, or plan to harm others/Mention of actual or potential domestic violence/Mention of weapons/Mention of abuse and neglect/Caller is incoherent/Report of use or misuse of drugs or alcohol/Caller is distraught/crying. etc...
Note: Refer to CTD pg. 11 Identifying a True Crisis Call 1-4
What does FPIL stand for?
Federal Poverty Income Limits
Referring to the Pluto Web Tool, who is the responsible area when indicating Medicaid-Precert Team and Medicaid-CST Team?
Medicaid-Precert: NCC Precert
Medicaid-CST Team:
What are the dental plans available to children, teens, and adults aged twenty or younger?
DentaQuest 800-516-0165 • MCNA Dental 800-494-6262 • UnitedHealthcare 877-901-7321
What is the OIG Lock-in Program?
A program that restricts, or locks in, a Medicaid member to a designated pharmacy.
Note: Refer to HCMS Training Doc.
In what circumstances will Carelon (pharmacy dept) override a member to obtain a medication from a pharmacy that is not their designated lock-in program?
Member moved out of geographic area (<than 15 miles for lock-in pharmacy)/Lock-in pharmacy does not have the Rx and not available for < than 2-3 days/Lock-in pharmacy is closed and member need Rx urgently.