VG
IF MEMBER STATES THEY DO NOT WANT TO FILE A GRIEVANVE, DO WE STILL FILE ONE?
WHAT IS YES, WE DO. INCLUDE A NOTE WITHIN THE CAG INTENT. (EX:MEMBER ADVISED THEY DO NOT WISH TO FILE A GRIEVANCE)
Can we assist with an appeal without a denial on file?
What is NO WAY JOSE!
IF MEMBER HAS A ROUND TRIP PLANNED WITH TRANSPORTATION VENDOR FOR TODAY BUT IS NOT PICKED UP FOLLOWING THE DR APPOINTMENT, IS IT STILL QOC CONCERN?
WHAT IS NO!
Do coverage determinations apply to part C (medical) benefits or part d (prescription drug) benefits?
What is part D
Do organization determinations apply to part C (medical) benefits or part d (prescription drug) benefits?
What is part C.
It is a decision made by the health plan related to part c payment, denial, or discontinuation of health services that the member believes he or she is entitled to.
True or False: If a member’s account has a grievance within the last 30 days, no new grievance intent is created.
WHAT IS FALSE!
It is not the number of days since the last grievance was documented that determines whether a new grievance is documented. It’s all about the status of the previous grievance.
If Open/Pending — do not document a new grievance
If Resolved/Completed —you should document a new grievance intent
Can you assist member with a pre-service appeal in Maestro after confirming a denial on file?
What is TRUE!
Pre-service appeals are not required to be submitted in writing. Initiate request in Maestro.
What must be included in documentation for the NAME, ADDRESS, and PHONE NUMBER sections?
NAME: TN CARRIERS/MODIVCARE TO SEE DR. ALEX SMITH
ADDRESS: GOING TO 1234 DOCTOR WAY, JACKSONVILLE, FL 33324 (PROVIDERS ADDRESS)
PHONE: 890-098-098 (PROVIDERS NUMBER)
WHEN SUBMITTING A CD, WHAT HAS TO FILLED OUT IN ADDITION?
WHAT IS PAS FORM.
What is the standard TAT?
What is 14 calendar days.
THIS IF FOR ANGELA & CINDY
ARE WE OR ARE WE NOT COMPLETING PRE CHECKER FORM THAT WE WERE FILLING OUT PREVIOUSLY?
For a post service denial, can we assist with an appeal through Maestro intent?
What is NO!
Post service appeals must be submitted in writing or request provider to submit an appeal.
If member is disabled or first language is not english, we can assist or reach out to provider.
Member was not picked up by Modivcare/TNcarriers and missed their appointment. What are the resolutions we should provide and document?
-confirm with providers office if they can still be seen today, if not offer to reschedule future appt
-reschedule trip if able to be seen today or for future appt if applicable
-if providers office confirms member can still be seen today but transportation can not confirm an estimated pickup time, reach out to UHC TRANSPORTATION ESCALATIONS DEPT. (keep modivcare or tncarrier on the line)
-document all appointment details (provider name, address, phone number) (transportation date time and reference number)
-if rescheduling is not an option and member has partial caid, request with vendor to remove trip from history
-email transportation vendor be sure to include this step in your resolution (cc angela in email)
-notate that member is satisfied
I cant take the preferred drug because of the side effects. I think the plan should cover the medication my doctor recommends a the price of the preferred drug.
As an advocate what would you initiate?
What is Coverage Determination.
Member has an upcoming doctor's appointment with Dr. Smith. When reaching out to transportation vendor, member is advised that their benefits have been exhausted. When completing MIOD, what would you list as the servicing provider/vendor?
What is Modivcare/TNCarriers.
WHAT IS YES! EXAMPLE: MEMBER EXPRESSES DISSATISFACTION THAT THEY CAN'T BUY ALCOHOL WITH UCARD.
provider name
service denied
date of service
claim number
reason for appeal
date of notice of denial/eob date
Member calls with dissatisfaction that her cardiologist charges a 15 dollar copay each visit no matter what insurance or coinsurance the member carries. Member understood there was a copay when she agreed to keep this cardiologist but does not wish to make a new appointment because she does not want to pay 15 dollars again.
Does this qualify as a QOC concern?
WHAT IS NO!
The following complaints are never handled as QOC grievances:
How a provider’s office handles copays / coinsurance
Member or member's provider call to check on CD/prior auth status. Member states that waiting the standard timeframe may jeopardize their life, health or ability to regain maximum function. As the advocate what is your next step?
-confirm status is still pending
A previous request was denied 36 days ago, member wants to submit another request for the same service. Can you assist member with a new MIOD?
WHAT IS FALSE!
A new request may not be submitted within 60 days for the same service. If the member still wants coverage, they must appeal.
Can a termed member file a grievance?
What is YES!
Only for things that occurred while they were active in the plan
What address do we provide member to send written appeal to?
FL: UnitedHealthcare Community Plan
Attention: Complaint and Appeals Department
P.O. Box 6106
MS CA 124-0157
Cypress, CA 90630
Fax:
Standard: 888-517-7113
Expedited: 866-373-1081
TN: UnitedHealthcare Community Plan
Attention: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131
Fax: 801-994-1082
Member calls in stating he has tried getting a referral to see an ENT provider for two months. Member states each time he calls his pcp, the office advises they will fax the referral that day but ENT office has not yet received referral.
As the advocate what are you next actions?
-reach out to ENT office to confirm retrieval of referral
-reach out to pcp to confirm referral request has been made
-file a QOC grievance related to delay in receiving a referral
Examples for when a CD would be completed.
Member is requesting reimbursement for a Part C service that the member paid for out of pocket for. As the advocate what do you advise?
An MIOD form submission is not appropriate for services already rendered. The member must submit a DMR form.