Communication
In an escalated situation relating to a sharing request, who do you contact if the need processor is not available?
Their lead (Kim or Sarah)
What term replaced 'Colonoscopy' in our preventive guidelines
Colorectal Cancer Screening
Name the 2 services that can be preformed at a annual provider visit that is not subject to the cap of $175.
Cervical cancer screenings and Prostate exams
The Sharing request a member submitted is not showing in the portal, what is the first thing that you should instruct them to do?
Log out and log back in
How can members ask for additional giving?
They submit an additional giving sharing request in their portal
A member has a question about their appeal determination, who do they speak with?
The DA who made the initial determination.
True or false: Zion HealthShare will share into the first colorectal cancer screening we receive for a member, as long as it is after the age requirement and the 6 month waiting period, even if it is diagnostic
False. The colorectal cancer screening must be preventive in order to be shared into
True or false: Only the office visit is shared into during an APV up to $175. Bloodwork and any other service rendered will not be shareable and will be considered member responsibility.
False: the office visit and any services rendered at the time of the visit and billed along with the office visit
True or false: Member care can take Maternity Time of service payments
False Member care can only take preventive TOS payments.
However member care CAN take qualifying Maternity IUA payments
How much notice does a member need to provide us in order to withdraw their membership?
24 business hours prior to their billing date
When is it appropriate to provide an update to the processor via the team channels relating to a sharing request? (3 reasons)
IUA being met, changes to their membership that affect a current open sharing request, or they have received a collections notice, the member care agent will post the update in one of the following teams channels depending on which team the assigned processor belongs to
How long after a member ages out do they have to submit a sharing request?
Medical incidents that occur within thirty (30) days of the members scheduled age-out at sixty-five (65), will have up to thirty (30) days after their membership end date to submit a sharing request. All other time limits will remain in effect including:
– itemized bills and statements must be submitted within six (6) months of the date of service, and
– the IUA must be paid within six (6) months of the date of service, or they become ineligible for sharing.
What is the age requirement for a prostate exam to be shared into during an annual provider visit?
50 years old
If no one is member care is available to take a preventive time of service call who do you transfer the call to?
The main Medical advocacy line
What additional service/s do Ultrio members have through Zion Healthshare?
Preventive
(they also have RXValet but it is through Planstin)
According to the warm transfer script, what are the steps in the warm transferring script that you must follow
Let the processor know who is calling, provide the reference number, explanation of call, initiation of transfer.
The guidelines for Chiropractic treatments, Massage therapy, Physical therapy has been combined into one section of the medical expenses eligible for sharing section of the member guidelines. What is this section called?
Therapeutic Treatments
Do newborns born out of an eligible maternity sharing request need to wait 6 months to access well child checks and youth immunizations?
No, as long as the the membership has had the preventive additional services added to the membership for 6 months or longer.
Who can request changes or the withdrawal of a membership?
The primary member or anyone on or off the membership who the Primary has signed a valid PHI authorization form for.
However individual members over the age of 18 on a membership that are not the primary may also request their own withdrawal without a PHI form.
What is the processing time frame we are able to provide to members for their sharing requests?
We are unable to provide time frames to the members however, their processor may set that expectation with them.
What is a MO, who do you contact regarding MOs, and how can they be reached?
MO = Marketing Organization
Jordan handles Marketing organizations, you can message in the Companies and Marketing organization team or call the affiliate line.
How are age related cataracts treated differently than non age related cataracts?
Age-related cataracts requiring multiple procedures may be shared with one (1) IUA if the second procedure is completed within three (3) months of the first procedure. Non-age-related cataract surgery requiring multiple procedures that is considered shareable requires two (2) separate IUAs.
What is a Medical Record Addendums and do we accept them?
A medical Addendum is when a provider corrects or adds to a medical record to provide information that was not available at the time of the original entry.
After the requested medical records have been reviewed and a determination is made, medical record addendums will not be considered unless they are combined with an official addendum from the applicable provider. The addendum must be separate and include the following:
– signature from the applicable provider,
– date,
– description of what was changed, and
– reason for change
When can member care change the status of a Sharing Request?
When the sharing request is closed and needs to be reopened when the member has provided the necessary information.
When did the Washington Cease and Desist take affect?
02/17/2022