B&E
A MD member stated we have her last name incorrect.
Which system do we use as a source of truth to confirm the last name?
Alvar
What system do we use to view prior authorizations for CO members?
ESSESTE
Member Name: Joseph Naddaf
Member ID: 131874168-02
Date of service: 04/21/2025
Claim number: 25J403037800
Issue: Claim was denied due to out of network service not covered and approved gap exception: A276432292 but does not cover for that DOS.
How will you assist the member?
Give appeal rights
What system is the source of truth for Texas?
Seed or Alvar?
Seed
Member Name: Pamela S. Bleything
Subscriber ID: 133039371-01
Why was RB4181565900 denied?
A: OON (Out-of-network services not covered)
Member Name: Jessica Hans
Member ID: 135008279
The member would like to cancel her plan, how can we assist the member?
Member must submit cancellation in writing.
What FORM will TX members receive that will be mailed out after they file a verbal grievance?
Texas One Page Complaint form
Member Name: Christine Eoff
Subscriber ID: 124805287
How much has the member met towards their individual deductible and OOP max?
Deductible = $871.86
$628.14 left
OOP = $1061.86
$1988.14 left
Member is wanting to process a refund - What system would we use for this?
Alexandria Elvira
Subscriber ID: 125696422
ORMB
Member Name: Ann Surjan
Subscriber ID: 122353383-01
Why was the prescription: CARVEDILOL TAB 12.5MG rejected on DOS 11/03/2025?
Refill Payable on or after 01/09/2026
When processing a 10 day free look back void, if the member has contacted the marketplace to request a termination. When does the policy term. Does the member pay?
The termination will be effective at the End of the Month and the member will be responsible for the premium.
What is the timeframe for sending a summary of an appeal to a Massachusetts member after filling a verbal appeal, if they do not waive it?
Massachusetts requires us to send a summary of an Appeal to the member within 48 hours of receipt, unless the member waives the summary.
Member Jesus Gaytan cardiel
Member ID: 131356875
Called in to verify a benefit in 2025. The member stated that they went to the podiatrist and wanted to confirm the benefit is covered. What would we advise this member?
Foot care typically includes cleaning and soaking the feet, trimming the nails, or removing corns or calluses.
Foot care is only covered for members that have:
Member Name: Billy Bailey
Member ID: 126061274
Did this member receive a MLR check for 2024? If yes, how much?
A: Yes
A: $692.73
Member Name: Keziah Jackson
Member Id: 130535540
What is the cost share & tier level for NICOTROL NS
A: 0% cost share, no charge, and the annual deductible does not apply.
A: Tier 1
Member Name: Mihn Crosby
Member ID: 125420669
Does the member have a subsidy, if yes how much?
Yes, $2383.00
Member cannot set up autopay online.
TRUE OR FALSE
FALSE
Member Name: Matthew Ebel
Member ID: 124249061
Claim: RA4536744900
Why was the claim denied?
A: Clinician Licensure Requirements Not Met
Member Name: Carlin Dean
Member ID: 123687734-01
Member stated we have her address incorrect and that it should be 23 FIREBETTY BLVD.
Using your resources, can we make the change?
*Disregard the termination*
A: No.
A: Facets/Maestro mirror Alvar
Member: Tania danissa Arevalo saavedra
Member ID: 134640123
Member is calling to verify the status of their Ozempic PA, What would i advise this member?
Member has Ozempic approved on July 1, 2026 under PA-H0367614
Member is calling from NJ, The member questions why their subsidy is lower this month? Who would they contact? What #?
Get Covered New Jersey
Member Name: April Martinez
Member ID: 129039379
Member says she has not received her $50 reward for completing the following:
Signing up for All paperless communications.
Signing up for All SMS/text Message communications.
Setting up Auto Pay.
Register their account at myuhc.com/exchange.
How will you assist?
Advise her the NM members are excluded from the $50 reward
Member Name: Sharon Thelen
Member ID: 127730143
Claim number RB2507348300
Issue: The claim was denied for OON, but there is a gap exception on file.
What is the authorization number?
How can you get the claim corrected
A: Member has an approved gap exception on file A293172788
A: Macces route
Navigation:
Share your screen and show me how to view Subsidy and Total Responsibility amount in ALVAR.
Member Name: Udita Markovich
Member ID: 128864688-01
Policy ID: 3921174
......
Member Name: Udita Markovich
Subscriber ID: 128864688
DOS 10/24/2025 MOUNJARO INJ-15MG/0.5
Member wants to know why does she have to pay $432.77, when she already met her deductible.
A: For TIER 3-a 40% coinsurance, after you pay the deductible.
In this case, the member had already met their deductible.