Find The SOP
Where can you find the 3 Principles of Advocacy?
E&I Toolkit home page
What are the 3 Principles of Advocacy?
Be Familiar, Anticipate,& Guide
Shane (MID: 952419100) calls in asking about bills from recently office visit. He mentions how stressed her is about the bills, but he needs the services because of his knee pain.
What nurse referral would be the most meaningful?
Managing knee pain - Decision Support
"ADVISED OF ADDITIONAL LAB WORK COVERED UNDER PREVENTIVE CARE PER THE EMPLOYER PSG. PROVIDED DIRECT CONTACT NUMBER."
Is this proper documentation?
No; does not clearly depict what benefit from PSG was discussed on the call, and the reason for the member's call.
Where would you find the triggers that need to be addressed in ACET?
Under Alerts, on the Advocate Actions tab
In what Advocacy would you find information regarding the MA-1099 Health Care Tax form?
Building Trust Through Advocacy
James, a Roche employee calls in and states that they have questions about services related to gender dysphoria and wants to know what their first step would be.
What would be your process on this call?
Get the members chosen name, phone number, and email, and any other information given to you, advise that Gender dysphoria related calls have to be handled by management, and email the leadership team. Advise the member of TAT and that someone from the leadership team will contact them.
Julie (MID:989550138) called in because she just found out she is pregnant. This will be her first child, she has a lot of medical questions, and she is inquiring about information regarding Pre-Natal vitamins.
What referral would be the most meaningful for her?
Maven 21 Month
Member calls in about a complex issue, while on the call they advise that they have to disconnect and ask for you to call them back. Name at least two things that you need to ask the member and document before a follow up can be completed.
1) permission to leave a voicemail
2) Callers phone number
3) TAT
4) reason the ors is being held
5) callers name
While on a call with a member you advise that they have a patient responsibility for a recent office visit with a dermatologist. What should you mention that might offset the out of pocket cost of the visit?
While on a call with a member you advise that they have a patient responsibility for a recent office visit with a dermatologist. What should you mention that might offset the out of pocket cost of the visit?
What advocacy would you use to inquire if a Specialty Pharmacy medication is covered under medical?
Pharmacy Advocacy
Melanie, a Duke member is having her first mammogram done. She is 42 years old and is planning to go to an INN clinic. How would this be covered?
It would be covered at 100%.
Barbara, a Roche employee calls in and wanted to inquire about coverage for diabetic test strips.
What nurse referral would be the most meaningful?
Diabetes Management
Glenn called because he got a bill from a providers office and is not sure why. After doing some research, you discover that the providers office billed the wrong insurance as primary, and they need to be notified so that they can correct it. The member has to disconnect to go to a meeting and you offer to call the provider on the member's behalf to update them on the issue. Name at least 3 things you need to document regarding the provider while making a commitment?
1) Providers phone number
2) How much they are billing the member
3) what information the provider needs to correct on the claim
4) which member they are billing
5) The Date of service
Tina, a Duke employee calls in about her son Conor. She wants to inquire about a bill for a recent annual checkup. She was expecting the checkup to be covered at 100%, but they are billing for some lab work and Tina wants to know why. Conor is 18 years old and you would need his permission to disclose any information to Tina. Luckily, Conor is there and is willing to HIPAA verify himself and give permission for his mother to speak on his behalf. Where would you update that information in ACET?
Go into the members's profile, go to Shared/Restricted Access in Member Details, and update the VROI on file.
A member called in because he never recieved his FSA depedent care reimbursment check from UHC and needs to have it reissued. What advocacy would I go to to determine how to have that reissued to the member?
Financial Advocacy
Tony, a Roche member called in because his doctor told him that he should get a colonoscopy because he has hemmoroids. Tony is 37 years old and this is his first colonoscopy. How would this be covered?
This would be covered at 100%.
Simone, a Duke employee is inquiring about mental health providers as she is stating that she has been feeling very stressed lately.
What referral would be the most meaningful for her?
Calm Health App
Craig, a Roche employee called in regarding two issues:
1) He wanted to inquire about coverage for shoe orthotics for himself
2) He wanted to inquire about a recent claim for his son, Jason. Jason is 11 years old and recently had an urgent care visit. You advise that the urgent care provider has not yet sent in a claim for the service as it only happened a few days ago.
How many different ORS should we have for documented on this call.
Two:
One for Craig calling in for himself and a second one for him calling in on behalf of Jason.
Peter, a Roche employee calls in and wants to know if UCSF hospital is In-Network for him to get an X-ray done. Once confirming they are In-Network. What document are you required to send to Peter via mail or email?
CAA correspondence letter
A 38 year-old male is calling in to confirm if CPT code 90651 & 97802 are covered as preventive?
90651: Yes, no Dx code required; ends on 46th birthday
97802: requires R73.03 Dx code; ends on 71st birthday
Member calls in stating that they are receiving bills for a DOS that they did not go into the office for after a CT with contract visit the week prior. You look at the claims, but do not know why the member is receiving a bills either. What would be the correct next step?
Advise you will need to preform additional research on the claim, confirm if there are any other DOS in question with this provider, confirm callback number with member, advise of HIPPA verification on callback, confirm permission to leave VM to number provided, recap call to confirm if there are any other questions or concerns, set commitment to follow up with member
Chris (MID: 986443497) calls in to ask what his OOP max is for the year and how much he has left. He mentions that he recently was diagnosis with coronary artery disease that may lead to multiple hospital visits so just wanted to confirm what the most he will be paying.
What nurse referral would be the most meaningful?
Case management
You faxed treatment records request letter to provider that stated they never received it originally. You confirmed the provider has received the fax, and advised the member the provider has confirmed the request was received.
Would you leave the case open until the treatment records are received or would you close the case until the member reaches back out to you or the main line?
Confirm the member has your direct number, advise of TAT and HIPPA on callback, and close the case until member reaches back out.
When on the line with member you advised "there are nurses available to you at no additional charge to assist you with your healthcare needs."
Would this be considered a meaningful nurse refferal?
No; This would considered a "general" referral; Did not specifically mention what nurse line being referenced