Basic Benefits
What type of Care Facilities provide services to patients to help them regain their strength and return home.
Post-Acute Care Facilities
What card could a member be eligible for that will help pay for their groceries?
Humana Spending Card
What are Preauthorization and referrals known as?
Preauthorization and referrals are also known as Utilization Management (UM).
What does SDoH stand for?
Social Determinants of Health (SDoH)
Who Can File a QAA Complaint?
The member must have an active Humana plan at the time of the incident to file a QAA complaint. Only the member, power of attorney (POA), or someone with an appointment of representation (AOR) can file a complaint.
Benefits for chemotherapy services must be searched in ____ under the term chemotherapy.
Debut
If a member calls with questions regarding Transportation, what Classification would you use?
Classification: Transportation
True or False:
An Authorization is requested by a provider?
True
What 3 steps will you take, to log into Guiding Care?
1. Type go/myapps in your browser's address bar, the hit enter
2. Type GuidingCare in the Search apps field and select GuidingCare Training when it populates.
3. When it opens, and signs you in automatically (it takes a minute), a dashboard displays with your name/title.
There may be times you receive a call where the member is showing signs of distress. What Mentor will be good to use?
Crisis or Critical Incident Calls for Medicaid
Accumulators (aka accums) are benefit counters. What do they track?
They track and display dollar amounts applied towards a member's deductible and coinsurance costs.
What is defined as an additional benefit that enhances a plan’s normal benefits. States mandate riders for Medicare members.
A benefit rider
What are the three types of Authorizations?
Prior Authorization-This is a request from a prescriber for a member to receive a specific medication or prescription. Obtained from the health insurer before the member can fill the prescription, or have the medication administered in the doctor's office.
Retrospective Authorization-This is an authorization that is requested after the medical services, treatments, tests have been received.
Concurrent Authorization-This occurs when an update or change is needed to an existing authorization for services that are currently being received.
This needs to be completed initially within the first 90 days of a member's enrollment and completed annually afterwards.
Health Assessments
Member dissatisfaction or disputes regarding their healthcare experience are classified into two topics; Grievance and Appeal. Please describe both Grievance and Appeal.
Grievances: Dissatisfaction about something other than a claim or authorization.
Appeals: Disputes with a medical claim processing outcome or authorization decision.
What website will you locate the Medicare Supplier Directory?
What is one example of Part B Drug or Medication that are not covered.
*Vitamin B12
*Investigational or Experimental Drugs
*Placebos
*Outpatient Prescription Drugs
*Medications for the treatment of Sexual Dysfunction (some of these drugs may meet the definition of a Part D drug, when prescribed for medically accepted indications approved by the FDA)
*Medications for Elective Enhancement (such as those used for weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging, and mental performance)
2 Parter Question:
1-What spreadsheet is accessed in Mentor via the Humana Customer Care Preauthorization and Notification List and 2-what is it used for.
Preauthorization and Notification List (PAL)
The PAL list is used to determine whether a medical service requires preauthorization, and who manages the preauthorization.
Care staff roles are referred to differently depending on the state. What is Care Staff role referred to for the state of Michigan?
Care Manager
(for BOTH South Carolina and Michigan)
True of False.
You will always be able to locate a copy of a Notification of Dismissal (NOD) letter that was sent to the member.
False.
NOD letters will not be in EMME. This means in order to identify the letter the caller is inquiring about, it will be necessary to ask them to read a portion of the letter to you.
Medicare: A Maximum Out of Pocket (MOOP) limit has no limit cap on the amount a member pays for their covered medical costs within a plan year.
False.
A Maximum Out of Pocket (MOOP) limit puts a cap on the amount a member pays for their covered medical costs within a plan year. Note: The MOOP includes both deductible and coinsurance amounts.
If you get a call regarding our wellness and incentive program called Go365 and the call becomes more technical, what do you do?
Call transfers to the Go365 team
Once the question or issue becomes more technical and out of your handling scenario, transfer the caller to the Go365 team.
What are the 5 types of potential outcomes of an authorization review.
Approved-Determined to be clinically or medically necessary subject to the plan's limitations and exclusions
Denied-Determined to not be clinically or medically necessary
Partially Denied-A portion of the service or item is not clinically or medically necessary
Pending-A decision has not yet been made
Voided-The request is either a duplicate, or preauthorization was not required
What are the 3 types of Critical Incidents?
1. Critical Incidents are events that negatively affect the health, safety, or welfare of a member.
2. Critical Incidents can include injuries that occur while receiving services from the Managed Care Plan.
3. Critical Incidents also cover Elder Abuse, which is the mistreatment of a community resident who is 60 or older.
What is the Expedited Appeal Decision Timeframe?
Per CMS guidelines, the timeframe of 72 hours to resolve a verbal expedited appeal begins once the appeal is received within the Grievance and Appeal department. It does not begin at the time of the call.