HIPAA
Grievances
NBA
Quoting Benefits
DSNP Vs. Medicaid
100

A phone number can be used as an indicator to HIPAA verify members. (True or False) 


False - Member ID, Address, Member ID, Member Full Name are the indicators needed to be compliant with HIPAA

100

A DSNP member calls in expressing a dissatisfaction with their medical benefit coverage but did NOT want to file a grievance. Is it required to file a grievance? (Yes or No) 

Yes - For DSNP members we are to file a grievance for verbally expressed dissatisfactions. If they do not want to file a grievance that must be noted within the intent. 

100

What system do you use to verify if a health assessment is completed?  

ICUE 

100

What is the annual maximum for dental for the 2024 year?

$3,000 pg#119

100
Unaligned member wants to schedule a ride to a doctor's appointment. They can schedule their ride with Modivcare. True or false. 

False... Member is unaligned. 

200

What does HIPAA stand for?

Health Insurance Portability and Accountability Act 

200

What are the 5 W's that are important for documenting a grievance?

Who, What, Where, When, and Why

200

If the member is in Hospice or hospitalized will we still need to address NBA's?

No... KM1007458 

200

Part A, B, C, or D covers skilled nursing services?

Part A

200

Which plan does the state offer?

Medicaid

300

What are the steps to finding an authorized representative in Facets.

Transfer, subscriber family, open customer, member,  respon. party

300

What system/site are you able to view A&G letters that have been sent to members?

Doc360

300

Which NBA assist members by identifying resources in their community they may be eligible for?

Social Determinants of Health (SDoH) 

300

This is the benefit category that includes services such as screenings, check-ups, and patient counseling, rendered to prevent illnesses, disease, or other health problems.

Preventive Care services

300

An aligned DSNP member who has NOT received cataracts surgery wants to inquire about vision coverage. You will quote member to their Medicaid or Medicare benefit? 

Medicaid Benefit - It advises that 1 pair of glasses or contact lenses (not both) every (24) months for both children and adults.
EOC : Pg#79 & 80 

400
Provider calls in WITHOUT the member BUT the member is fully verified. Provider has questions about a members claim being denied. You can speak with the provider to see why the claim is denied. True or False?

False, must send provider to provider line

400

Which KC would you use to identify what type of grievance should be filed?

Grievance Categorization... KM1005774 

400

What does NBA stand for?

Next Best Action

400
A member wants to know how many transportation rides they have left. What are the two ways to verify?

They can reach out to modivcare or review medical benefits: Transportation

400

October-December is the time of the year where the Dual/LIS SEP CANNOT be used. What is the acronym used to describe the fourth quarter of the year?

AEP

500

True or False: A new email address cannot be added without the members verbal consent?

True... KM1007997

500

What 3 things cannot be a QOC grievance towards a provider?

1. Copay amount

2. How a provider's office handles copays/insurance

3. Collections

KM1005774

500
What do you offer the member after you have verified that they have completed NBAs such as the flu shot, annual wellness visit, and health assessment?
Offer to update their rewards
500

What are the 3 Medicaid Eligibility Levels?

Full Medicaid, QMB only, Partial Medicaid

500

These are the three minimum requirements to enroll in a DSNP plan. 

Qualifying Medicaid level, part A/B, and lives in the plan's area

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