Compliance
Connection
Hipaa
Random
UHC surprise
100
True or False- Advocate should NOT submit VG if member declines for one to be submitted.
False- When the caller's complaint meets Verbal Grievance guidelines, the Advocate MUST submit a Verbal Grievance regardless of whether the caller wishes to do so.
Per- Verbal Grievance Category Selection Assistance 07132018 v3 SVC
100
True or false- When there is a significant life event mentioned (deaths, recent serious diagnosis, upcoming surgeries, etc.) and The advocate does not recognizes and acknowledges the member appropriately given the feel and tone of the conversation it is considered an Error.
True- Failure to recognize a life event of this nature, where appropriate, is considered an error.
100
If member information is provided via the IVR, and a popup displays the member's ID number and DOB is the member fully verified?
Yes, there is no need to have the caller repeat the information provided through the IVR.
100
Is Prescription medications purchased outside of the United States (including in Canada or on any cruise ship) covered by Medicare Part D?
And will member be reimbursed if paid out of pocket?
No, United Healthcare will not pay for or reimburse any cost associated with medications purchased outside of the United States.
100
what is the Senior supplement claim address and timely filing?
claims address
ALL states
PO Box 31359
Salt Lake City, UT 84131-0359
Senior Partners
15 months (450 days)
200
What will assist in reducing the applicable reasons, sub-reasons, and resolution for the verbal grievance?
Compliance Accuracy Tool
200
When receiving an internal transfer or having a conversation with an individual from another department with UHG, Is compassion required?
Compassion is not required, but the advocates should have a courteous interaction.
200
Once IVR has been completed, the member's ID number and DOB will populate on the screen pop, How should you greet the member?
"Hello, am I speaking with <Mr./Mrs. (Member's First and Last Name)>?
200
2019 Standalone plans- During the coverage gap what is the percentage of coinsurance member will pay for generic drugs (non-Low Income Subsidy [LIS]) or brand name drugs?
37% coinsurance for generic drugs (non-Low Income Subsidy [LIS]) or 25% of the total cost for brand name drugs, for any drug tier during the coverage gap.
200
where can you check to see if prior Authorization has been submitted on members behalf?
RX claims
300
When completing the Complaints, Appeals and Grievances intent, Advocates MUST read?
"Apologized to the caller and advised the plan takes these grievances very seriously" statement as it is written or use something similar to convey the same sentiment.
300
True or False? Misdirected and Prospect calls require compassion.
False- Misdirected and Prospect calls do not require compassion however the advocate does need to acknowledge constituent's negative reactions and significant life events when appropriate.
300
What Can be Discussed After the Authorized Representative Has Been Authenticated?
Basic Plan Information (methods of disenrollment, formulary lookup, etc.)
- Member Enrollment Information(payment methods, etc.)
- Member Claims Information
- Member Medical Information (Includes Advocate4Me Next Best Actions
) - Premium Billing Information (Minimum Necessary)
300
what is Out-of-Pocket Costs?
The amount you pay (or others pay on your behalf) toward the cost of your prescription drugs including any deductible, copays, coinsurance and payments made in the coverage gap. Premiums do not count toward Out-of-Pocket costs.
300
Who handles Nationwide Senior supplement plans payments?
Wage works is now taking the payments for Nationwide.
400
What is a coverage determination and the action you should take to submit one?
A decision about Part D payments or benefits to which a member believes he or she is entitled to.
A request to cover a specific medication.
Document the request in Maestro – whether or not the member wishes to continue!
Check RxClaim and PAS to ensure a CD hasn’t already been requested.
Submit the request in PAS and document.
400
When speaking with a authorized representative including ( broker and providers) should a connection be made during the call?
Yes, a connection should be made during the call.
400
Should we speak with Broker?
If you can what must be authenticated?
what must be on the members application?
Member First and Last Name
- Any two of the following:
- Member's ID
- Medicare ID
- HICN - last 4 characters only or
- Medicare Beneficiary Identification Number (MBI)
- Complete permanent address
- Date of Birth
- Agent's Full Name (First and Last Name) OR Caller's Full Name and Agency Name (see Notes and Exceptions below)
- Brokers/Agents: Any one of the below;
- Delegates/others calling on behalf of the agent: Any two of the below:
- Writing ID #
- Party ID #
- Tax Identification Number
- National Producer Number
- *** Brokers ID must be on member application****
400
The AARP MedicareRx Walgreens plan's preferred retail pharmacy network is limited to what
pharmacy(s)?
The AARP MedicareRx Walgreens plan's preferred retail pharmacy network is limited to only Walgreens and Duane Reade pharmacies.
400
how would you process a Premium Payment Verification Letter is member has a Senior supplement plan?
we wouldn't, a RSS associate must issue the letter for Senior Supplement plans.
500
What is a Tier Exception? and what tiers are not qualified for one?
•A request that the plan cover a higher tier medication at the cost of the next, lower tier. A tier exception request can be made for any covered drug that is in tiers 2, 3, or 4 on the member's formulary.
Tiers 1 and 5
500
If a member calls in, and have a plan under your line of business. but need to be transferred over to another department for assistance such as (Credit Cards or Optum RX) should a connection be made with caller prior to transferring?
Yes, a connection should be made prior to Transferring the call due to account being something that we can handle.
500
Is it okay to speak with Members employer group regarding Members plan with us?
The name of the caller must be documented as an Authorized Representative.
500
for the state of Florida what is the Monthly premium and annual premium for the AARP_Medicare_Rx_Preferred plan?
Monthly Premium-$76.60
Annual Premium- $919.20
500
how can we update Member's Name or DOB through MiiM?
we can not , member must contact SSI for any personal updates such as Name or DOB.