Basic Benefits
Durable Medical Equipment (DME) items are a covered expense as long as it meets the definition of medically necessary as specified in the member's Evidence of Coverage or Summary of Benefits document. Where can you access DME?
DME benefits are accessed in Debut via the DME category button.
True or False:
Dual Special Needs Plans (DSNP) members will automatically qualify for Healthy Options Allowance but can only spend their funds on Over-the-Counter eligible items.
True.
DSNP members will automatically qualify for Healthy Options Allowance but can only spend their funds on Over-the-Counter eligible items. In order to spend their funds on Healthy Options eligible items (groceries, rent, utilities, etc.), members must now have one chronic condition to qualify. Member's may qualify for this benefit via claims (verified by one chronic condition diagnoses on a claim).
It’s the member’s responsibility to be sure a preauthorization is on file. So, we need to provide guidance if the necessary information is on file to be sure members can use their benefits to the fullest.
Care staff roles are referred to differently depending on the state. What state refers to their Care staff role as Care Coordinator?
Care Coordinator in Illinois
What plan does a member need to have if they need to file a Quality, Attitude, and Access to Care complaint?
The member must have an active Humana plan at the time of the incident to file a QAA complaint.
The Member Plan section of the Person Account page in CRM contains, what?
The Member Plan section of the Person Account page in CRM contains additional information you may need to reference. They include the Member ID and Product fields.
Medicare doesn’t pay for eyeglasses, unless the member has had cataract surgery. However, specific Humana plans may include a Vision rider, which has a co-payment and covers one pair of eyeglasses annually.
Who reviews medical necessity for Part B billed medications and enters the approved or denied preauthorization into the medical claims system.
Humana Clinical Pharmacy Review (HCPR) Team: Reviews medical necessity for Part B billed medications and enters the approved or denied preauthorization into the medical claims system. Note: these calls are also handled by fully skilled advocates only.
What is the largest network of free and reduced-cost social assistance in the United States?
Findhelp
If you receive a call from a distressed member, what mentor for Medicaid will help you with the call?
Crisis or Critical Incident Calls for Medicaid
A member is always responsible for any premium payments for their Humana Medicare plan, any copayments for physician services, and costs for non-covered services.
General inquiries: What are my benefits? Can you help me schedule a ride? Can you confirm a reservation? How many rides per year do I get?
Complaint calls: For example: “I scheduled a ride and specifically asked for a wheelchair accessible vehicle, but the driver showed up in a compact car!”
Stranded calls: “My ride never showed up to take me home. Now I’m stranded at my doctor’s office.” These calls are typically escalated.
Authorization could mean Preauthorization, but it could also mean another type of authorization? What are the other types?
Prior Authorization: Obtained from the health insurer before the member can fill the prescription.
Retrospective Authorization: This is requested after the medical services, treatments, test have been received.
Concurrent Authorization: Occurs when an update or change is needed to an existing authorization for services that are currently being received.
1. Type go/myapps in your browser's address bar
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.
True or False:
Members are notified once a decision has been made on their plan benefit or authorization requirement.
True.
PARE is the acronym used to remember the four provider types. What are the 4 provider types?
Pathologists
Anesthesiologists
Radiologists
Emergency Room physicians.
____ covers the services that may affect people with diabetes. A member must have a Medicare medical plan to get the services and supplies Part B covers.
Part B covers the services that may affect people with diabetes. A member must have a Medicare medical plan to get the services and supplies Part B covers.
Part B also covers certain preventive services for people at risk for diabetes.
What is the difference between a preauthorization and a referral.
A preauthorization is required.
A referral is not required.
Medicare or Medicaid:
Refer to the applicable state-specific Health Assessment document to review options to complete the assessment.
Medicaid
When supporting members in behavioral health crisis situations, call advocates should still use probing questions, focusing on open-ended and empathetic approaches.
Free 400 Points for the reader and/or team!
Where would you research to access skilled nursing care benefits?
To access skilled nursing care benefits, search Skilled Nursing or just Skilled in Debut.
How are members able to view their Spending Account Card account?
Members can log in to their NationsBenefits account via the MyHumana app. Members will have access to the same features as the website and more. Members can also download the MyHumana mobile app by visiting the App Store® or Google Play® on their Apple or Android device:
What are the types of potential outcomes of an authorization review.
Clinical Guidance eXchange. (CGX) is used throughout Humana by many departments and teams. When would you use it?
Non-Indiana state This system is used throughout Humana by many departments and teams. In your role as a Medicaid Calls Advocate, you will research Care Staff and send tasks using CGX 2.0.
Please explain Grievance and Appeal
Grievances: Dissatisfaction about something other than a claim or authorization.
Appeals: Disputes with a medical claim processing outcome or authorization decision.