Enrollment/Eligibility
You would use this process document if a member was calling in to check and see if we have received enrollment/if plan is active?
Enrollment and Application Status Calls
You would use this mentor to help you research when there is an issue with a pharmacy claim.
Pharmacy Claim Research
This is the mentor that tells you how a specific vaccine is covered (Part B vs Part D)
Medicare Immunization Coverage Reference
This overview has everything to do with Coordination of Benefits (COB)
Medicare COB Overview
This overview is all things related to HIPAA
HIPAA Overview
This overview gives you the definition of a Cancellation, Disenrollment, Retro-Cancellation, and Retro-Disenrollment.
Cancellation and Disenrollment Medicare Overview
You would use this mentor to assist a member who needs to know what information is required to file a claim for reimbursement.
Information Needed to File or Submit a Claim
You would use this mentor process for every Verification of Benefits (VOB) call you receive.
VOB for Group Medicare
Member receives notification/letter about other insurance, and you would use this mentor to walk through it.
Member Response to Coordination of Benefits Notification
This mentor will go over the different methods of Consent that are available.
Consent Methods Overview
You would follow the steps in this mentor when member calls in about their plan being terminated.
Medicare Termination Calls
This mentor is used to help you figure out a pharmacy claim denial and what actions to take next.
Actions for RxNova Error Codes
If a member calls in about issues with their Routine/Non-Emergent transportation benefit, you would use this mentor.
Routine Non-Emergent Transportation Overview
The member is calling in to update their medical insurance. Which mentor walks you through this process.
Update Medical Other Insurance Medicare
This overview goes over all things related to a Power of Attorney (POA) Executor of Estate.
Power of Attorney and Executor of Estate Medicare and Medicaid Overview
A member might call in for a letter or some kind of proof of the enrollment if they haven't received their ID card. You would use this mentor to provide the proof.
Provide Proof of Eligibility
This mentor is used when the member states the claim outcome is different than what was previously quoted by customer service.
Claim Paid Differently Than Expected Due to Benefit Misquote
A diabetic member calls in to inquire about their supplies. You would pull up this mentor up to help them out.
Diabetic Supplies Inquiries Medicare
PDP member calls in to update his Other insurance on file, so you pull up this mentor to help walk you through it.
Update Medicare Pharmacy Other Insurance
Which mentor would you use to help authenticate and verify you can share certain information with someone who doesn't have a consent.
HIPAA Job Aid Reference Medicare and Medicaid
Member has joined another carrier on accident and wants their Humana plan to be reinstated.
Reinstatement Due to Joining with Another Carrier
You would use this overview to locate the BIN/PCN number for member or pharmacy.
Pharmacy Claims Overview
This mentor is going to tell you all about the new prescription drug law went into effect to provide enhanced benefits for Medicare members. They might see a cheaper insulin and $0 cost on certain vaccines.
Inflation Reduction Act Overview
This mentor will help you enter an override/authorization for a medication when the member has a COB discretion.
Enter an Authorization for Coordination of Benefits Issues
If a member isn't able to give verbal consent and has a special situation you would follow this document.
HIPAA Job Aid Consent Form Special Circumstances Scenarios