HIPAA
What information must a caller provide for a disabled member if they are unable to speak?
Members information: First/last name, DOB, complete full address and member ID. (Last 4 of social if member ID not available) Do NOT request full SSN.
Callers' information: First/last name and relationship to the member.
In the call record, document caller information and detailed description of the call.
If a member is aligned, can we see the Medicaid part of the claim and what Medicaid paid?
Yes. View the Medicaid plan that aligns with the DOS of the claim under Review Medical Claim History intent in Maestro.
How can you view the denial/rejection reason for an Rx?
Under the claims messages on the Rx claim, or searching the denial code in knowledge central.
Under the summary tab, what is Members Engagements used for?
A summary of letters sent to the members from UHC that we can view with timestamps.
What benefits are not covered for a Medicaid member? Name at least 3.
Immunizations related to travel/work, art therapy, employment physicals
If a member verifies their information through the automated system, what does the advocate need to verify? If it is not the member that called, but their information was verified, what does the advocate need to verify?
Member calling IVR verified: First/last name.
Not the member: Members verbal consent
What does Network Std Fee Sched mean on a claim?
Provider billed Medicare more than what Medicare is allowed to pay.
Can we view Rx claims for Medicaid members?
No,you will need to call OptumRx to get claims information.
Where can you find the part D claims address in maestro for a DSNP member?
Under summary tab located where prescription plan is.
If a member states her provider is not showing active, but we see that their plan shows active, as well as the state, how would you assist the member?
Call the provider to confirm they have the members correct insurance information on file.
What must be authenticated when a caller calls on behalf of a deceased member? What can be discussed after authentication?
Member: first/last name, DOB, and one of the following- member ID, Medicare ID, complete address, Medicaid ID, last 4 digits of SSN.
Caller: first/last name, relationship to the caller.
Basic plan information, medical claims, member enrollment information
What is provider denial liability?
Limitation on liability for charges that Medicare does not pay. The member is not responsible for this cost and cannot be billed to the member.
Which intent can we view Rx claims for DSNP members?
Claim history intent
Where can you find the part C claims address in maestro for a DSNP member?
Summary tab under recent medical claims section
What specialists do not require a referral for Medicaid members?
Behavioral Health and OBGYN
When a broker/agent is calling in on behalf of the member, where can you find them listed on the members account and how do you open the account?
Select member contact screen, select broker/agent from dropdown, select broker/agent name and submit.
What tab under a medial claim can you locate the providers information? In what instance would you need to contact the provider?
Provider Detail tab. Contact provider to confirm they billed the members correct and current plan and provide correct information to bill to if necessary, such as member ID and/or medicaid ID.
Is weight loss medication such as ozempic, wegovy, tirzeptide, etc. covered under the members plan?
No, unless the PA for the Rx includes a diabetes diagnosis.
Where can you find a DSNP members MBI?
Under the member tab, it will be the Medicare Claim Number.
For Medicaid members, how would you send the member an AR form by mail?
Macess
What is considered an emergency situation for HIPAA guidance? What is included and what is NOT included?
An emergency situation occurs when a member is hospitalized, temporarily incapacitated, or unavailable due to a health issue.
Includes members who recently experienced a medical emergency, such as a stroke or heart attack, or who were involved in an accident.
Does not include members with ongoing medical conditions persisting for months or years.
How can you tell what level Medicaid the member has and if they are responsible for any cost shares?
Review Medical Claim history intent will tell you what Medicaid level the member has and if they are responsible for cost shares before you search for the claim.
If we locate an Rx claim, and we see it was billed under the members Part B instead of Part D, what is the best course of action to take?
Call their pharmacy and ask them to run the Rx under their Part D so it will be covered and only have to pay the copay according to their LIS level instead of member paying OOP or an outrageous cost.
Where can you find the reason a DSNP member's plan was terminated/disenrolled?
In maestro under the plan tab
How long is a newborn covered under the mother's plan after birth? What does the state need in order to enroll baby in their own plan?
30 days. The state needs the baby's SS number.