HIPAA

Maybe POA

100

What needs to be verified on Inbound Calls?

• The agent confirms that we are speaking with the correct person (this does not count as a verifier)
• Members must verify two identifiers from the list below
  • Date of birth
  • Health Plan / Product ID 
  • In absence of Health Plan / Product ID we can validate the following as a last resort
    • Address and Phone Number

200

when reaching out to a member and a 3rd party answers the phone, can we continue the phone call with the 3rd party?

NO, we can only speak with the member or if the 3rd party is listed as a POA/AOR

300

Where would a 3rd party mail the HIPAA forms?

• If the caller wants to send in their HIPAA Release of Information form:
  • Medicaid members fax to: [phone]
  • PDP members fax to: [phone]
  • CCP members fax to: [phone]
  • Medicaid members mail to:
    Wellcare Health Plans
    PO Box 31372
    Tampa, FL 33631-3372
  • CCP/PDP members mail to:
    Wellcare Health Plans
    ATTN: Enrollment Department
    PO Box 31378
    Tampa, FL 33631-3370

400

if a member's spouse is calling to update their address status and is getting mad due to them not being on the account, what should you do?

Apologize to the 3rd party and let them know we must get verbal permission from the member first since they are not listed as the POA/AOR

500

What is considered General Information you can give to a unauthorized third party?

The following information is considered general information and can be disclosed to any person that requests the information:

*Names of Providers or any healthcare facility available through the Health Plan

*Benefits offered as medical coverage

*Covered medications

*Names of available Over-the-Counter products, Co-pays

*The company's mailing address, including claims address

*The company's information that has been made public through website, flyers or materials mailed to customers.

Examples include, but are not limited to covered states, benefits offered, Stock information, names of Wellcare's Board of Directors, Officers, controlling parties, Owners and Partners including their names, addresses, and titles

Movies

100

True or False

HIPPA is still verified if members leave off "st" at the end of the address?

False

We must have the member verify their full address as it appears in the system.

if member is missing "st", we can offer hints like, is it "Dr", "Rd", "Blvd". any hint instead of "st"

200

How long are AOR's good for?

AORs are good for one year.

300

True of False

If a call is transferred to you from member services HIPAA does not need to be verified?

False

If the agent that spoke to the caller prior to you and did not advise that they already verified the member's information, you must verify the information in order to proceed with the call.

400

What is the verbage in the script that must be read to 3rd party after verifacation?

we must provide the following verbiage to confirm it is okay to speak with the third party on behalf of the member and make changes on their account: 

"Okay, thank you. Do I have your permission to speak with [Authorized Representative First Name] [Last Name] on your behalf to today to discuss your plan and make any changes on your account?" 

500

What do you do if a third party states there is an emergency or urgent care situation?

If member's health is at risk and it is a life and death situation, you can provide the caller a one-time courtesy to be able to access and makes changes in the member's account. Please make sure you inform your supervisor of the one-time courtesy provided to the caller.

Benefits

100

What needs to be verified on Outbound calls?

• We should confirm the member's full name, as it appears in the system.
• In addition to two of the following:
  • Date of birth
  • Address
  • Health Plan / Product ID

200

If a phone call gets disconnected and a Manual dial is made to the member. Does the recording statement and HIPAA need to be verified again?

Yes

The Disclaimer and HIPAA need to be verified on all phone calls, even if the phone call just disconnected a second ago.

300

If a HIPAA form is returned and is incomplete or denied, can you let the 3rd party know the outcome or reason?

NO

you cannot disclose any information to the third party unless the member is there to provide their verbal permission to speak to the caller on their behalf or its generic information. 

Notes for incomplete documentation are entered in F4 notes. Grievances, Appeals and Claims issues may be filed and or discussed with an AOR and is only good for one year after the AOR is received.

400

What is the verbiage in the script that must be provided to the 3rd party before speaking with them?

If you encounter an unauthorized third party, you must go to Section 4 of the Welcome Call script. 

First, you must request to speak with the member to verify HIPAA and obtain permission to speak with the third party:

"May I please speak to the member for verbal authorization to speak with you?"

500

What is the time frame for an AOR?

An AOR form is only valid up to one year from the signature day on request, and can be revoked by the member at any time with a written request

3rd party

100

True or False

AOR's cannot give verbal permission for someone else to speak on their behalf?

True

• AORs cannot give permission for anyone else to speak on the account. Only the member can give verbal permission for anyone else (besides them or the AOR) to speak on their behalf.

200

If Verbal Permission is granted for a 3rd party to speak on the members behalf, how long is the verbal permission good for?

• If verbal permission is granted, the third party can access the account for seven days

300

If an AOR is calling to update the members address, can you assist the AOR and make the change on behalf of the member?

NO

• AORs do not have the ability to make changes to information on file (address, PCP, phone number, etc.).

400

What is the Time frame of a POA?

A POA does not expire until Wellcare is notified in writing that the member no longer wishes the person to be their Health Care Power of Attorney (POA), or upon the Member's death

500

What does HIPAA protect?

a U.S. law designed to provide privacy standards to protect patient's medical record and other health information provided to health plans, doctors, hospitals, and other health care providers. Developed by the Department of Health and Human Services, these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed.