HIPAA
DSNP
CAID
CHOICES
MISC
100

WHAT IS 3 VERIFICATIONS OF HIPAA

FIRTST AND LAST NAME 

MEMBER ID 

BIRTHDAY 

FULL ADDRESS 

100

WHO IS MEMBERS DENTAL INSURANCE 

UHC DENTAL 

100

HOW CAN I SEND A PROVIDER'S DIRECTORY TO THE MEMBER 

MACESS ROUTE 

100

WHAT IS THE ELIGIBILITY FOR CHOICES 


  • Live in the state of Tennessee.
  • Must be 65 years of age or older OR an adult, 21 and older, with a physical disability.
  • Medicaid eligible.
  • Meet Medicaid criteria for payment of Level 1 (see below) nursing home care.
  • Have a safe home where one can receive HCBS.
  • Be able to get services in the community at a cost less than that of nursing facility.
100

WHAT ARE 8 THINGS ON YOUR CALL THAT YOU ARE SUPPOSED TO DO 

HIPAA

AAR

PROVIDE RESOLUTION

NBA'S

RECAP

OFFER FINAL ASSISTANCE

PROVIDE NUMBER 

BRAND CALL 

200

What Can Be Discussed After Authentication for a member 

  • Basic plan information
  • Member enrollment information
  • Member claims information
  • Member ID number
  • Missing documentation
  • Sales agent/broker name and phone number 
  • Member Medical Information (See Note below)


200

WOULD YOU FILE A GRIEVANCE FOR A MEMBER WHO CALLED IN AND STATED THAT THEDIR UCARD HAS BEEN STOLEN 

NO, GET THEM OVER TO SOLUTRAN

200

MEMBER CALLED IN ABOUT RECEIVING BILL FROM A VISION PROVIDER. HOW CAN I HELP THIS MEMBER 

CALL MARCH VISION AND CONSULT ABOUT BILL DON'T TRANSFER DUE TO MARCHVISION DOESN'T TALK TO THE MEMBERS

200

IN ICUE WHAT ARE THREE THINGS WE ARE LOOKING FOR WHEN WE FIRST GET IN 

LTSS INDOCTOR TO SAY NO 

INSURNACE TYPE- MEDICAID 

END DATE TO 12/31/9999

200

WHAT IS A 6 MONTH GRACE PERIOD REFERRING TO 

WHEN A DSNP MEMBER HAS LOST CAID THEY HAVE 6 MONTHS TO GET IT BACK OR THEY WILL LOSE THEIR DSNP PLAN 

300

Guidelines for All Callers what not to do for Auth Rep, Broker, Parent/Guardian, POA, Trustee Outbound Calls 

  • Unless instructed to state member or caller first and last name in an outbound outreach, do not volunteer information.
  • Do not provide Medicare Beneficiary ID (MBI) to anyone but the member, unless otherwise indicated in the individual caller type job aid.
  • C&S and IFP: Do not provide Medicaid ID (C&S), SSN, or credit card information to anyone, unless otherwise indicated in the individual caller type job aid.
300

WHAT IS THE CO-PAY FOR A LIS LEVEL 1 

GENERIC- 4.90

BRAND- 12.15

300

WHEN DID DENTAL QUEST CHANGE TO RENAISSANCE

NOVERMBER 1 2025 

300

IF THE MEMBER CALLS IN AND SAY THEY HAVE A LETTER STATING THA THEY ARE ON THE WAITING LIST, WHAT DO YOU DO 

GET THEM OVER TO THAT STATE TO SEE ABOUT STATUS UPDATE 

300

WHEN DOING A GRIEVANCE, WE MUST PULL UP WHAT KC 

Verbal Grievance Categories (Medicare & DSNP)

4/11/25

 km1679207

400

What Can Be Updated for a Deceased Member 

The following information can be updated by Legally Designated Persons only:

  • Plan premium method of payment (MOP)
    • From EFT to Monthly Bill only (when notified of the member's passing). Refer to Notification of Death - TRR 90 Code Not Received.
  • Temporary address
  • Phone number
  • Do Not Call (DNC)
  • Do Not Mail (DNM)
400

UNALIGNED MEMBER RAN OUT OF RIDES AND NEEDS MORE HE HAS A DOCTOR'S APPOINTMENT NEXT WEEKEND. WHAT CAN I DO TO HELP THIS MEMBER?

GET THEM OVER TO THEIR MCO BECAUSE THEY HAVE RIDES WITH THEM 

400

MEMBER CALLED IN BECAUSE THEY RECIEVED A DENIED LETTER FOR THEIR MEDICATION AND WOULD LIKE TO FILE AN APPEAL. HOW WOULD YOU FILE THAT APPEAL

MAESTRO 

ROUTE THROUGH MACESS 

400

MEMBER MOM IS CALLING IN STATING THAT SHE NEEDS CHOICES FOR HER 4 YEAR AUTISTIC SON. DO WE COMPLETE THE CHOICES REFERRAL 

NO THIS IS ECF CHOICES AND MOM WILL NEED TO COMPLETE THE ONLINE FORM 

400

DOCUMENTION NEED DESCRIBE WHAT DETAILS

WHO, WHAT, WHEN, WHERE 

500

IF A THIRD PARTY CALLS IN AND THEY ARE NOT LISTED ON THE ACCOUNT AND THE MEMBER ISN'T AROUND, CAN THEY CALL THE MEMBER ON THREE WAY TO GET CONSENT?

  • A third party cannot conference the member and we cannot call any number provided by a third party. 

  • Important:  Do not add a third party to the conference call until obtaining verbal consent from the member.

500

MEMBER CALLED IN BECAUSE THEY RECEIVED A BILL. YOU LOOKED IN REVIEW MEDICAL CLAIMS AND SEE THAT IT SAY SEND CARRIERS EOB. HOW CAN I HELP THIS MEMBER 

CHECK ICUE FOR COB 

500

MEMBER CALLED IN BECAUSE THEY RECEIVED A BILL IN THE MAIL 

CALL THE PROVIDER AND ASK THEM TO STOP BILLING THE MEMBER BECAUSE ITS ILLEGAL FOR THEM TO BILL A CAID MEMBER. 

BILL BALANCE GRIEVANCE IF THEY SAY THEY WILL NOT STOP BILLING 

PROVIDE THE PROVIDERS LINE NUMBER 

500

MEMBER CALLS IN AND WANTS TO GET CHOICES STATES THAT THEY NEED HELP WITH CLEANING THEIR HOME, TRANSPORTATION TO GROCERY STORE, AND TAKING CARE OF THEIR DOG. HOW CAN I HELP THIS MEMBER 

THIS IS NOT CHOICES THIS IS THE OPTIONS PROGRAM WE WILL GET THEM TO AAAD

500

DO WE CALL THE OTHER INSURANCE WHEN WE ARE TO COMPLETE A COB 

NO, WE DO NOT 

M
e
n
u