Systems/Applications
Where do we look up appeals?
ATS
*Some ETS, but very few anymore
What is the SOP you would use to assist a member with community baby shower program in NC?
KM1964752 - NC Medicaid-Value Added Benefits or
KM1268354 - NC Baby Shower Job Aid
A NY Medicaid/UHC Community Plan member is calling today because the went to get a Rx and it was denied. Why is this?
We don’t carry NY CAID pharmacy, for NY CAID it is carved out to State - Medicaid Toolbox
What is the SOP used to change a PCP?
KM1273654, Seach and Assign Provider Intent (Medicaid)
What system do you use to verify a members Medicaid eligibility?
RPA
When doing a pharmacy rebuild, what is the name of the document you need to open to get the info needed to do rebuild?
CAG - KM1206310
What is the phone# for Medicaid (PRIME/RAE) for state of CO?
#800-421-6204 KM1759952 or
Medicaid Toolbox provides:
#800-421-6204 PRIME/RAE region 1
#800-541-6870 RAE region 2
OH Member is calling to request change to his Pharmacy Lock-In. Which SOP would you use to assist this member?
KM1265502, OH CSP-Lock-in Pharmacy change/override request (C&S)
MI Member is calling and wants to add a provider group as their PCP - Is this allowed?
No - KM1273654
If a member calls to add or remove a COB for his whole family, what is the process? What SOP would you use to assist him?
Submit via Macess -KM1266404, COB (Medicaid)
*Each member MUST be a separate submission to add or remove a COB.
When flipping a flag for a member, what system do we use?
Next Gen - KM1421615
In NM, what are the limits for acupuncture?
Up to 5 visits per year, $75 per visit limit, specific codes apply
*KM1757357 - NM Medicaid Value Added Benefits
Member #101777726 calling on 12/15/25 to find out why Rx for Montelukast Tab 10MG denied?
Surplus limit 20 has been met/exceeded - Refill too soon - next fill on or after 12/30/25
Who is the vision provider for MD Medicaid members?
March Vision, Medicaid Toolbox
Member #127039274, is calling for the status of appeal (AT-977122-K). What can you advise member?
Resolved, UHC contacted providers office this amount has now been written of and member has 0.00 balance at their provider office.
When a member calls to request a Case Manager, what system do we use and how do we assist?
Community Care or ICUE (state dependent)
Then, Add task
What is the vendor and phone # for non-emergency transportation for NY?
Medical Answering Services (MAS) #844-666-6270
KM1902816 or KM1236005 (Transportation/CAID):
Downstate #844-666-6270
Upstate #866-932-7740
What is the Rx Bin, Rx Grp and Rx PCN for a MD Medicaid member?
Rx BIN: 610084
Rx Grp: ACUMD
Rx PCN: RXSOLPRD
KM1206310 - CS Pharmacy CAG Lookup or Medicaid Toolbox under ID Card Images
A FL Member is calling on 12/14/25 to change their PCP effective today. She has already seen another PCP this month. Are you able to make the change?
Change will need to be for 1st of the next month - KM1273654
Member #128451810 is calling to inquire about status of claim for DOS 9/15/25 - claim# 25Q920444300. What would you advise member?
This claim has been adjusted, new claim number 25Q920444301, claim is now paid, with 0.00 member liability.
Where are the two (2) places to look when verifying a pharmacy prior authorization?
Rx Claims Book 1
PAS
What is the Value Added Benefit that lets you earn up to three (3) retail gift cards for enrolling & completing prenatal and postpartum visits?
Babyscripts - KM1443014 Babyscripts Mobile App
Member #100461328 calling to see if have Pharmacy Lock-In. Do they have one? If so, who is it?
Yes, Walgreens #5833, effective 10/25/2024
1801 FM 1765 Rd
La Marque, TX 77568
When updating the members PCP, you may receive an error message. There are only three instances where an override is allowed after receiving the providers permission. What are they?
Provider is not accepting new patients/PCP Panel Full
Provider is not accepting patients of that age
Provider is not accepting patients of that gender
KM1273654
For NJ address changes made in Maestro, they are temporary and will revert after how many hours? And who must members contact for the address to become permanent?
Revert after 24 hours & Members must contact the state for the address to become permanent.
*KM1258715