Medicaid Escalation Team

Pharmacy

100

Which states have a PBM/ we don't handle pharmacy issues for? 

KY- KENTUCKY (Medimpact)
OH- OHIO (Gainwell)

200

MET resolves pharmacy issues relating ATC involving...
(Mentor: MET Pharmacy Overrides MCD overview)

-Plan discrepancies
-Plan activation in RxNova system
-72-hr emergency fill overrides
-Other NON-CLINICAL overrides may occur

300

Which are the IN Scope RX Error codes for MET? 

002 (if mbr reinstated--Active in CI & plan needs to be updated in RXNova)
007
540/541/090
462
474 

400

OK MCD mbrs normally have a $4 Rx Copay. TRUE OR FALSE?
(OK MCD Overview- under Pharmacy, Copayments) 

TRUE.
 There's a cost sharing program in effect for Oklahoma for members with the $4 copay.

• Note: Medical and behavioral services don't have copayments
  • The following members are exempt from cost sharing requirements and don't require a copay for prescriptions:
  - Children 20 and under
  - Persons receiving pregnancy-related services
  - American Indian and Alaska Natives from a federally recognized tribe
  - Persons receiving nursing home care or hospice care
  - Persons in the Oklahoma Breast and Cervical Cancer Treatment Program
  
  - For all other members over 21, prescriptions have a $4 copayment.
  -Each month after the member's household meets a 5% cost share based off the monthly household income, copays are waived.
  -The monthly household income is determined at the time of enrollment. The member's circumstances may change and the member may go on and off the copay exemption list.
  
  Example: If a member's monthly household income is $1,000, they'd pay a $4 copay for each medication each month until they reach $50 (5% of $1,000). Then, they wouldn't pay any copays for the rest of the month.

500

If mbr is unable to obtain RX because provider hasn't responded to PA sent (In scope issue for MET), How would we handle the call?

(Escalated Pharm Prior Authorization Calls MET) 

We'd Make up to 3 outreaches (few different times of the day in a 2 day period) to provider office to provide HCPR contact info to submit PA (HCPR extension/give external#, HCPR fax#, or electronically: covermymeds.com/epa/Humana)

Appeals

100

Which types of callers can we speak with to file appeals & service type:(Medical, Pharmacy, or both)? 

-Members, member representatives (Both: Medical & Pharmacy)
-Providers (Pharmacy only)
 
**If caller is provider & issue is about a Medical service/Jcode med they are wanting to appeal, it would go to Provider services/PCC.**

200

Expedited Appeals can be used for authorizations & claims. TRUE OR FALSE.
(Expedited & Standard Appeal Calls MET or Webchat)

FALSE. 

• Expedited appeals are for authorizations only, and never to dispute a claim.

300

When filing an appeal, do we ask the caller if they want to file the appeal expedited?

(Mentor: Expedited and Standard Appeal Calls MET or Web Chat)

No. The Expedited Appeals Team makes a judgment call based on the information that the caller has provided.

-------Definition of expedited appeal: If the caller/member is disputing the way that an authorization processed and the standard appeal time frame could:
--Seriously jeopardize their life or health, or
--Seriously jeopardize their ability to regain maximum function

400

If Provider, mbr rep/ unauthorized caller is wanting to file an appeal, which document's needed by G&A before appeal can be worked? 

--AOR/ Appointment of Representative form
--POA/ Power of Attorney (Legal will confirm if POA is eligible for appeal filing upon receipt-- we're not legal)

500

For IN Aligned Members, which method would appeals be filed?
(Mentor: Expedited & Standard Appeal Calls MET or Webchat, under standard appeals- Step 3) 

If the services was denied, reduced, or terminated by Medicare, appeals must be submitted in writing or there are notes with specific reasons on why it can't.

unless the member meets one of the criteria below.
-Disability
-Illness
-Illiteracy

*If mbr meets one of the criteria, we can file appeal verbally, just document in case notes of appeal of criteria mbr meets for verbal appeal**

Behavioral Health

100

FL ABA- Caller is 35 and looking for an ABA Therapist, which team/dept would handle the call?

(Mentor: BH Incoming calls overview MET & CAS Mental Health List MCD)

The BH Vendor (Lakeview/Access BH or Carelon BH) depending on mbr's region. 

**This call would not come to MET due to caller being over age limit for ABA Therapy for plan**

200

FL ABA- Mbr is aged 4 & already had diagnosis/evaluation, mbr's parent needs help finding ABA therapist.

What specialty do we search for in FindCare/ PFP? 

Behavioral Analyst ONLY

300

MET/The Behavioral health Team assists with Provider calls. TRUE OR FALSE? 

(Mentor: CAS Mental health List MCD) 

FALSE.
The Behavioral Health team is a Humana team within CCC Member that only assists with member calls.

--If the caller is a provider and the table indicates that the Behavioral Health team handles the inquiry, transfer them to CCC Provider.
--If a vendor handles the behavioral health inquiry, advise the provider to contact the vendor and provide the phone number.

400

Which states do we handle BH calls for?
(Mentor: CAS Mental Health List Medicaid) 

-FL (ABA only) 
-IN Pathways
-KY
-LA
-OH (non-OH Rise mbrs)
-OK
-SC
-VA

500

For ATC issues (when an In-network provider can't be located for the member), who is the mbr put in contact with?
(Mentor: Behavioral health Incoming Calls Overview MET)

the Care Manager/Care Coach
**Not NAL**

COB

100

What's the In Scope Scenarios for MET for Medical COB issues?
(Mentor: In & Out of Scope Call Transfer to MET Medicaid) 

1. It's been more than 30 days since the case was sent to Other Insurance Investigations.

2. The member disagrees with the case decision.
2. There was no resolution (on COB case) 

200

What's the In Scope Scenario for MET regarding Pharmacy COB issues? 

COB case has been sent to OI Investigations, but mbr has "Submit to Primary Payer" 540/541/090 error on pharmacy claims. 

300

Which system(s) do we verify mbr's OI coverage before entering 090 override. 

CI/CAS- CRI Screen & PEOC Screens
MARX/Wipro- for verifying no Orig. Medicare/PDP is active

400

When entering a 090/COB override for an eligible mbr (that disputes having OI), how many days is the override entered for? 

30 days total, including today's date.

Example: If entered today, dates would be: 10/21/25- 11/19/25

500

After taking the call transfer, we find that previous rep didn't send COB case-- How do we handle call?

(Mentor: COB RX Claim Denial MET) 

Update the priority on our/MET case to High & Route our case to COB team (Keep the case open)

• Service Center: Billing and Reconciliation
• Department: Coordination of Benefits
• Topic: Error 090 Prescription Drug Plan Override

Sup Calls

100

When we get a Sup call (on any of our In scope plan types), what Mentor should we be using on those calls? 

Medicaid Escalations Team Document Index >
Account Supervisor Calls Medicaid Escalations Team

200

When we get transferred a sup call to the Account Supervisor Queue, how will we know? 

There will be a whisper tone "Supervisor call"

300

When handling Account Supervisor Calls (for In scope plan types), which call types/issues would we handle? 

ANY/ALL issues (per the Applicable State index) 
We may be making outreaches on behalf of mbr/caller or connecting caller to another dept/vendor depending on the issue/concern.

400

VA only-- Providers that call in on behalf of the member to request a supervisor are handled by MET Acct Supervisor line.
TRUE OR FALSE? 

TRUE.
Providers that call to request a supervisor for themselves are handled by the provider supervisor line.

500

When assisting a caller, even if the issue is resolved we always file a complaint. TRUE OR FALSE? 

TRUE.
Unless the caller volunteers that they don't want to submit a verbal grievance or complaint, and wants to withdraw the complaint or grievance:
1. Document "Caller expressed they don't want to submit a verbal grievance and wishes to withdraw the complaint."
2. The Yes box from complaints fiild is unchecked & case is closed.