KA Navigator
How can a member request an Explanation of Benefits (EOB) that is older than 7 years?
A. Call the customer service number on the back of their member ID card.
B. Submit a letter requesting the EOB(s) to the claim address on the back of their member ID card.
C. Visit the insurance company's website and fill out an online request form.
D. Email the insurance company's support team with the request.
B. Submit a letter requesting the EOB(s) to the claim address on the back of their member ID card.
What happened to the Synapse Health process introduced in March 2023 for members needing specific DME items?
A. It has been expanded to include more services.
B. It has been discontinued effective immediately, except for breast pump coverage.
C. It has been discontinued effective immediately for all DME items.
D. It has been merged with another service.
B. It has been discontinued effective immediately, except for breast pump coverage.
John, who has not updated his COB with UHC, he receives a text message informing him that his Coordination of Benefits (COB) prior update is about to expire. What options are given to John in this text message?
A. Contact Optum COB IVR line at 888-262-4001 for the update to a Yes or No.
B. Reply to the SMS message to update their COB status.
C. No response is needed if the member has indicated refusing other insurance in the past and the answer is still no.
D. A&B
D. A&B
True or False: Advocate received call which noticeably have unusual pronunciation and lacks a natural accent. The caller identified herself as Ruby Ford. Advocate also got confirmation after asking, “Am I speaking with a bot?” Call has to be disconnected immediately.
TRUE
Pre-determination requests for covered services can only be completed if the following are true:
A. The UnitedHealthcare plan is secondary.
B. The service has already been rendered.
C. The UnitedHealthcare plan is primary and the service has not been rendered or ongoing.
D. None of the above.
C. The UnitedHealthcare plan is primary and the service has not been rendered or ongoing.
Member is inquiring how choosing Designated Diagnostic Providers (DDP) for outpatient lab and major imaging services benefit him in terms of cost and coverage. How would the advocate deliver answer positively?
A. "If you choose providers outside the DDP network, you may face higher out-of-pocket costs and receive less value for your diagnostic services."
B. "Choosing DDPs means you'll pay less out-of-pocket and save more on your diagnostic services, making it easier to manage your healthcare costs. We're here to help you get the best value for your care"
C. "Opting for non-DDP providers can lead to paying the full price for your services, as you won't receive any cost share benefits."
D. "Using providers outside the DDP network means your services will be covered at the lowest tier, leading to the highest cost share and more out-of-pocket expenses."
B. "Choosing DDPs means you'll pay less out-of-pocket and save more on your diagnostic services, making it easier to manage your healthcare costs. We're here to help you get the best value for your care"
True or False: John changes his plans within UHC (different policy numbers) and his Situs is Wyoming (WY). His RX prior authorizations granted from previous policy can be honored for 90 days after the enrollee's effective date.
TRUE
According to the internal policy, what is the time frame allowed for a member to provide notification that a claim needs adjustment?
A. One year from the date the claim is processed.
B. Six months from the date the claim is paid.
C. Six months from the date the service is denied.
A. One year from the date the claim is processed.
Mary would like to get their controlled substances prescription filled via Optum Home Delivery, what should Mary do?
A. Fax the prescription to Optum Home Delivery.
B. Provider to mail a new written prescription to the appropriate Optum Home Delivery address.
C. Use the same prescription for multiple fills.
D. Allow up to five business days from the date Optum Home Delivery receives the prescription to receive the mail order delivery.
E. B & D
E. B & D
Maria's claim was closed with a 7Y code for Coordination of Benefits (COB). She recently updated her COB information. It's now been eight days since the update and the claim has not been reprocessed. What are the things advocate should do to provide resolution?
A. Determine if this is an initial or repeat issue.
B. Determine if the Received Date is within the last 6 months
C. Check if the claim has been denied with remark code B5 or show a rejected status
D. Advise member that claims will be given a second look.
E. All of the above.
E. All of the above.