Jeopardy

Intents

100

What intent would you use to order a rx DMR? Medical DMR?

^{RX= Send non marketing Materials, Medical=Go through the Medical Claims intent.}  

200

What intent do you use to assign, reassign, or remove an AR?  

^{Manage Auxillary Persons}

300

What intent do you use to do a Compassionate embrace?

^{Compassionate embrace intent}

400

What intent do you use to find if a RX is covered for teh year?

^{Formulary look up}

500

We use the National DME list for vendors but to find local vendors to what intent would we use?

^{Search and Assign a Provider (rally)}

Job Aids

100

What job aid do you use when filing an MIOD? (2 main ones)

^{Member Initiated Organization Determinations - Index   2021-12-08 KM1007586} 

^{Submitting MIOD Requests  2021-12-04 KM1005245}

200

You have called the transportation company and they say they can not find the member.  What is your next step?

^{Make sure the representative can do the state the member is in.  (They are different call centers)}

^{Jab aid is:}

^{Wellness Benefits - Transportation   2021-12-08 KM1004470} 

^{There is an email that will have to be sent}

300

What job aid do you use to look up a fax number?

^{Fax Numbers  2021-10-08 KM1213755}

400

What job aid do you use to find your National DME Sharepoint?

^{DME Vendor Website Look Up - Index   2021-08-24 KM1004252}

500

What job aid do you use for Navarro Pharmacy?

^{South Florida Health Plans (SFL)   2021-12-02 KM1004244} 

^{When calling them they do not find member under Navarro.  You must say to look under these two terms:  Preferred Care Partners (PCP) and Preferred Care Network (formerly Medica HealthCare Plans)}

Hipaa

100

If the IVR pops up when member calls what information is needed to verify?

^{Full name only}

200

When verifying a caller and you hear member in background is that enough to verify caller?

no

300

When verifying member how many verifications do you need and what dcan you verify?

³

^{Member ID}

^DOB

^{Full Name}

^Address

400

When a broker calls in what has to be verified after members information is verified on broker?

^{Agent's Full Name (First and Last Name) OR Caller's Full Name and Agency Name*}

^{Brokers / Agents: Any one of the below:}

• ^{Writing ID Number (Also known as the agent number)}
• ^{Party ID Number}
• ^{Tax Identification Number}
• ^{National Producer Number}

500

On an outbound call what needs to be left on a voicemail of member if applicable?

^{If the provider is not available, a general message may be left on voicemail as long as no member identifiers (DOB, member ID, etc.), plan specific information, or Member Medical information is included. Reference HIPAA - Definitions for examples.}

Random Ally

100

When documenting a caller what is the information you are answering to document properly?

Who, what, when, why, and how

200

What are "flex benefits " members refer to for 2022.  

The OTC and food benefits alot of our members plans may have.  Allows a certain amount on their card loaded at beginning of month they can use for food or OTC in any formula not to exceed their amount for the month.  

300

When a member needs to speak to their navigator what is the job aids and the place you go to enter a note for navigator?

^{Situational Guidelines - Navigator Hand-off Process   2021-11-08 KM1260277}

^{Nav4Me button on the summary bar.  After recent interactions.  Only if navigator is listed on account.}   

400

What is the turnaround time for Standard Appeals.

^{Standard Medical Pre-Service Appeals}

^{30 Calendar Days}

^{Medical Claim Appeal Review (Post Service)}

^{60 Calendar Days}

^{Part B (drugs)} 

^{7 Calendar Days} 

^{Part D}

^{7 Calendar Days}

^{Senior Supplement}

^{30-60 Calendar Days}

500

When making a commitment what is the rule on time frame and on making them?

^{48 hrs,} 

^{NOt on days off}

^{NOt on MONDAYS}

^{Generally maybe not on weekends if you need providers that are closed on weekends.}  

Xtra

100

Attorney calls inquiring on matters concerning subrogation or liens would be handled with what job aid?

^{Subrogation Services   2021-08-04 KM1007023} 

^{If you receive a call from:}

• ^{A member, or a family member}
• ^{An attorney}
• ^{Property/ Worker's Comp/ Other health insurance carrier}
• ^{A physician or other provider} 

200

What is your hold speech?

^{Suggested Scripting: Mr(s) <caller's name>, may I place you on hold for 1- 2 on hold while the issue is researched/resolved> while I research this information?}

300

When coming back on the line after placing the caller on hold what is the first thing you say to caller.  

^{Reconnect with the caller to express appreciation or acknowledgement for being on hold.}

^{Examples may include, but are not limited to:}

• ^{Thank you…}
• ^{I apologize…}
• ^{I appreciate…}

400

What is Pt A, B,C,D mean in terms of care?

^{A>Hospitals (Medicaid)}

^{B>Physicians (medicaid)}

^{C>UHC riders (dental, vision,ext)}

^{D> Rx drug coverage (LIS)}

500

When a member asks for more meds bc theirs were lost what can you do for member?

^{KC>Transitional Override}

^{Call optum Help Desk to see if medicine qualifies for override.  If it does then you can call pharmacy and have it rejected.  You call optum back and they will override.  You call pharmacy back to let them know it has been override and they can fill.}