Grievances
When a member is calling and is concerned because a previous advocate was rude to the member about the Spending Account card issue when answering the questions. What is the correct grievance?
Benefits package grievance
Quality of service grievance
Member refused grievance rights
Spending Account Card
Quality of Service
Melanie is calling because her friend Victoria has CarePlus, and Melanie wants the same health plan as Victoria, but she doesn't know what plan is that, what would do in this case?
We advise the caller to visit CarePlus website and see details on the plans available or advise we can transfer the call to DMS and assist the caller with the health plan according to the caller's needs.
A VAIS describes:
A discount available to all CarePlus members on specific services including vision.
A discount available to some CarePlus members on all services including vision.
A discount available to certain CarePlus members on limited services including vision.
Discounts aren't available to CarePlus members an
A discount available to all CarePlus members on specific services including vision.
What is the maximum distance we are able to schedule a trip in EpicRide?
1 mile
20 miles
35 miles
50 miles
100 miles
35 miles
The STC CP435 code is used to document a verbal consent.
True
False
False
Regarding Oral grievance, what would you document when the member is refusing the grievance rights?
Open the corresponding STC in CSC indicating the member doesn't want any further research or resolution.
In a normal case, how long does the member have to submit an appeal?
30 calendar days from the notice of denial.
60 calendar days from the notice of denial.
30 calendar days from the date the claim was submitted to CarePlus.
60 calendar days from the date the claim was submitted to CarePlus.
60 calendar days from the notice of denial.
For a bedbound member after surgery is calling to request a transportation service, what type of level of service would be needed?
Strecher
The transportation exception is included when the member states they need to go to the pharmacy, they did not pick their medication.
True
False
False
What is the STC code we use to transfer the call to any other department?
C0336
C0421
C0336
Which details should be gathered by the advocate with each grievance?
The 5 W's: Who, where, when, what, why
Do we handle dental calls?
No, we transfer the call to Humana Dental
When the member has exhausted the rides available, what is the organization determination authorization request needed?
Member forgot to schedule the ride.
A grievance has been submitted.
Benefit reinstatement.
There is a prior authorization on file.
The transportation exception will be for approved locations in the case there is a valid reason for the urgent trip.
True
False
True
What is the STC to be used when transferring the call to Humana Dental?
C0336
C0421
C0421
When we have a third-party caller showing as CPHI to complaint on the member's behalf regarding that they should have a higher balance currently, what STC code do we use?
File a benefit package grievance type if verbal consent is obtained, or a CP435 - Unable to authenticate SCT if no verbal consent.
A C0422 - Spending Account cards if verbal consent is obtained.
Do not document anything since the third-party caller is a CPHI.
A quality of service grievance type if verbal consent is not obtained.
File a benefit package grievance type if verbal consent is obtained, or a CP435 - Unable to authenticate SCT if no verbal consent.
The member needs to see an eye doctor because of the dye eye syndrome, what specialist should we refer the member to?
Primary Care Physician
Gastroenterologist
Ophthalmologist
Cardiologist
Optometrist
Opteometrist
For an urgent trip, what is the correct STC code to be used to document?
C0201
C0306
C0177
C0095
C0095
What is the STC code for Self-Service adoptability for the member to schedule trips through the app?
C0381
Where do we transfer the call when we have a member with Careneeds Platinum plan, what is the extension #?
CarePlus Spanish 139-4329
CarePlus English 139-4328
CarePlus Spanish 139-4310
CarePlus English 139-4311
CarePlus English DSNP 139-4310
What case category do we use to file a grievance in CRM for transportation? Classification and intent
G&A > Benefits/Transportation
The member calls and states that they received their pair of glasses, not in the color they have ordered them, they are asking to replace this pair of glasses, how would you assist the member?
Call the provider to see if they can replace the glasses.
Explain to the member there is nothing we can do.
Initiate a benefit reinstatement organization determination.
Document the call as Quality-of-service grievance against the vision provider.
Initiate a benefit reinstatement organization determination.
What STC code is used to educate the member with a transportation benefit?
C0201
C0306
C0177
C0095
C0201
Do we offer the Eliza survey to a CPHI caller for a transportation service scheduled?
Yes
No
No
Where do we transfer the call when we have a Spanish member with Careneeds Platinum plan, what is the extension #?
CarePlus Spanish 139-4329
CarePlus English 139-4328
CarePlus Spanish 139-4310
CarePlus English 139-4311
CarePlus Spanish DSNP 139-4311