Determine Eligibility
If Streamline shows different eligibility information than Dynamics 365, return to step 2 and proceed based on the eligibility information in Streamline.
What is the KA for Non-Member Inquiries?
01106
What are the two ways a member can file a grievance?
CareSource MyLife App or by calling in
What is the KA for locating a provider?
01375
What system do you use to check eligibility through the state?
MITS/PNM
Should you give the member or non-member their MMIS number if they do not have a profile in D365?
Do not relay the member's MMIS # if there is no profile in Dynamics.
How do you create a case for a non-member that has never had CareSource?
Press New Case from the home screen and add a contact in the "on behalf of" field.
Member calls in to complain about Cleanliness of an Office Site. What is the subject of your case?
Complaint Against Provider
What is a good resource to use for finding DME providers?
Access Resource Guide
What systems can you use to locate providers?
D365 and Find A Doctor
HIPAA; 3 pieces of information
What do you advise the member if they got a letter to choose CareSource as their MCP (managed care plan)?
What is the KA for reporting a complaint against transportation?
01125
Is a referral required to see a Chiropractor?
No
What is the name of the tab in D365 with the wrench?
Case Record
Who does the case get routed to if the member is showing active in MITS/PNM but not in Streamline or D365? How long does it take for them to update it?
ENROLLMENT; they will be notified of a resolution within 48 business hours
What do you do if the non-member who is Medicaid eligible wants to switch to CareSource from another MCP?
Provide the phone number to the Medicaid Hotline and offer to transfer the caller to enroll.
When filing a complaint against transportation what do you need to do after filing the complaint in D365?
Call Provide A Ride for the member to file a formal complaint with them
What system do you use first to locate a provider for a member?
D365
What system should you be using to double check eligibility, and updating a PCP only if D365 isn't working?
Streamline
When do future members' profiles generally get posted in D365?
within five days of the effective date
What do you do if the non-member is not Medicaid eligible and wants to join CareSource?
They can contact their local County Department of Job and Family Services for further assistance or they can apply for benefits on the Medicaid website at medicaid.ohio.gov.
What is the timeframe for a grievance to be resolved if its not due to not able to obtain medical care, or receiving a bill?
30 calendar days
How many providers should you give the member at a minimum?
2
What is the name of the system used to take calls? This also tracks breaks, lunches, and not ready statuses.
Bucher and Suter