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
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?
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