Cost Share
Name the pushback used when provided a copay for the J-code.
And coinsurance?
Name the task note used for a separate department.
What is: Plan administered by {Separate Department}; contact: {XXXXXXXXXX}.
Agent states provider is in network, name what benefits you collect.
In Network
Agent states there is a medical group or IPA that handles prior authorization. Name the process for the rest of the call.
Ask for medical group name and phone number, confirm with resources that it is a legitimate medical group, if so: ask buy and bill question and get reference number.
Request transfer to medical group.
Make sure to mark as escalated and take as human for the medical group.
Ask Referral, prior authorization, Predetermination, and step therapy requirements.
True or False: The administration code can require Predetermination even with the J-code requiring prior authorization.
True
Agent gives both a coinsurance and a copay amount for the administration code, name the pushback (if any) and what is inputted.
No pushback, enter the copay for the administration code.
This task note is used when an agent requests the recording to be stopped.
What is: Payer representative did not allow call recording.
Agent states provider is out of network, name the pushback required.
"Can you check the network status of the practice...."
Agent states prior authorization expired over 30 days ago, name how to mark the prior authorization on file.
Mark as "not on file"
Name the task note needed for when Predetermination is required and not on file for any code.
What is: Predetermination required for XXXX code. Contact XXXX Department at XXXXXXXXXX.
Agent states cost share is $$$ "per visit", or "when done in a SOV/HOV", name the pushback (if any) and what is inputted.
No pushback needed, input copay.
There is no need to pushback for standalone benefits when they say "per visit" or "in a SOV/HOV".
We ONLY pushback if they say "WITH" or "FOR" a SOV/HOV.
This task note is used when provided different tiered benefits, name both that can be used in this scenario.
What is: Obtained tier X benefits OR
Agent states provider AND practice are out of network, name the steps you need to take and what benefits you need to collect.
Ask if patient has out of network benefits, if yes collect in and out of network benefits. If no, collect in network benefits only. If agent refuses to give in network benefits and there are out of network benefits, collect out of network benefits. If agent refuses to provide in network, and there are no out of network benefits, GE and add task note.
Agent provides a start date that is different from the PBV PA on file. Name the pushback (if any), and what to do.
"Can you check that please, I normally get a different answer in similar situations."
If agent keeps answer, escalation required to PA department to confirm dates.
If agent changes answer to reflect the same date on PBV PA, good to change to match.
Name the biggest difference between OptumRx, OptumSGP, and Optum Care.
OptumRx and OptumSGP are NOT medical groups
Optum Care IS a medical group
Agent states cost share depends on which tier the doctor falls under, what pushback should be used?
If agent does not know which tier, collect all tiers available and notate in internal team notes with applicable customer task note.
This task note is used when the PA department will not speak with us.
What is: Prior authorization department will not speak to third parties.
BCBS agent asks if provider is "INN with their local", name the pushback that is required.
Pushback: Can you check that please? I don't have that information.
Agent states there is an approved PA on file for our codes and provider, however, all units/treatments have been used/exhausted. Name the pushback and task note required.
"Is there a different, active, prior authorization on file for the same codes and provider?"
If yes, collect active PA information.
If no, mark as "not on file".
Task Note: Representative confirmed all units/treatments have been used on approved prior authorization.
Agent states that Optum Care is the third party for this plan. Name the questions you ask before transfer and what questions you ask the medical group.
Ask for medical group name, phone number, then ask buy and bill questions. Request transfer to medical group to ask for referral, prior authorization, Predetermination, and step therapy requirements.
Name the pushback required for when the out of pocket maximum has been met
What is: I understand that the out of pocket has already been met, can you answer the following questions as if it had not been met?
OR
Is that true even when the out of pocket has not been met? <<typically used after receiving cost share benefits
BCBS commonly tells us to do this for step therapy.
What is: Refer to medical policy for step therapy.
BCBS agent asks if provider is "INN with their local" and is unable to verify network status after pushback. Name the process to verify network status and what benefits to collect.
Check BCBS website.
If provider is listed and address is the same, collect INN benefits.
If provider is listed with a different address, collect INN and OON benefits, input address from website in appropriate prompt.
If provider is not listed, mark as "Unknown" and collect INN and OON benefits, ask how to be considered in network.
Agent states PA is on file, for a different provider. Name the pushback and process to follow.
"Is the prior authorization valid for the practice XXXX, at XXXX?" If yes, mark as approved and collect information.
If no, ask: Can any provider use this prior authorization?
If yes, mark as approved and collect active PA information.
If no, mark as "Approved for different provider"
Agent states that Jcode, admin code(s), and SOV/HOV are covered in full, no copay, no coinsurance, deductible does not apply, plan pays 100% of allowed amount. Name the pushback (if any) needed.
Just to confirm, does the patient have any financial responsibility for any of these products or services?
OR
So the plan pays 100%?