ORGANIZATION
DETERMINATIONS
COVERAGE DETERMINATIONS
VERBAL GRIEVANCES
APPEALS
QUALITY OF CARE
100

WHATS THE TURN AROUND TIME FOR A STANDARD MIOD?

14 CALENDAR DAYS?

100

WHEN IS IT APPROPRIATE TO ACTIVELY OFFER TO FILE A CD?

NEVER

100

IF A MEMBER HAS 3 COMPLAINTS UNDER THE SAME SUBCATERGORY, HOW MANY GRIEVANCES WOULD YOU FILE?

1

100

WHICH APPEALS MUST BE SUMBITTED IN WRITING?

POST SERVICE APPEALS

100

A COMPLAINT INVOLVING MONEY WOULD NEVER BE CONSIDERED A QUALITY OF CARE GRIEVANCE. TRUE OR FALSE?

TRUE

200

WHAT FORM NEEDS TO BE SUBMITTED ALONG WITH THE MIOD REQUEST IN MAESTRO?

THE INFOPATH FORM

200

WHAT FORM NEEDS TO BE SUBMITTED ALONG WITH THE CD REQUEST IN  MAESTRO?

THE PAS FORM

200

THERE ARE 3 DIFFERENT COLORED NOTES IN THE COMPLAINTS, APPEALS AND GRIEVANCES INTENT (BLUE, GREEN AND RED). 

WHICH COLOR NOTES MUST YOU READ AND FOLLOW?

  • Red: Red notes have a hand icon and display job aids for specific flows, important messages, and disclaimers.
    • You must review and follow all red notes.
  • Blue: Blue notes have a book icon and provider basic instructions for you to follow.
  • Green: Green notes display a light-bulb and display best practices.
200

WHERE IN MAESTRO WOULD YOU LOCATE A RECENT APPEAL FILED FOR A MEMBER?

UNDER THE A&G CASES, TAB, ATS (APPEALS TRACKING SYSTEM) CASES INFORMATION

200

A QUALITY OF CARE GRIEVANCE CANNOT BE AGAINST AN ONN PROVIDER? TRUE OR FALSE?

FALSE

300

WHO CAN SUBMIT AN MIOD?

THE MEMBER

THE POA

THE MEMBERS PROVIDER THROUGH THE PROVIDER LINE

ANY OTHER CALLER WITH THE MEMBERS PERMISSION (MAKE SURE TO DOCUMENT)

300

WHAT IS THE PRESCRIPTION PLAN TILE AND WHERE IS IT LOCATED? 

THE PRESCRIPTION PLAN TILE IS LOCATED IN MAESTRO DIRECTLY UNDER THE HEALTH PLAN TILE ON MAPD PLANS AND UNDER THE BILLING TILE ON PDP PLANS. THIS TILE HOUSES THE MEMBERS PART D CLAIMS ADDRESS, LIS DETAILS, RX COB FLAG INFORMATION, PART D CLAIMS WITHIN THE PAST 180 DAYS, PRESCRIPTION COVERAGE STAGE SUMMARY AND PRIOR AUTHORIZATIONS (INCLUDING CONTINUATION OF CARE (GRANDFATHERED) AUTHORIZATIONS). 

300

WHERE SHOULD I LOOK TO FIND THE CORRECT REASON AND SUBREASON DROPDOWNS TO CATEGORIZE A COMPLIANT/GRIEVANCE?

GRIEVANCE CATERGORIZATION JOB AID

300

AN APPEAL REQUEST CAN BE FILED WITH 2 DIFFERENT PLACES. WHO ARE THEY?

QIO AND UHC

  • If an appeal has been filed and accepted with the QIO:
    1. An appeal cannot also be filed with UHC at the same time.
    2. And the appeal request is upheld, the appellant is not able to file an appeal with UHC, the appellant must be redirected back to the QIO for a reconsideration as the QIO made the determination.
300
YOU SHOULD ALWAYS REACH OUT TO THE PROVIDER/FACILITY INVOLVED IN THE QUALITY OF CARE COMPLAINT TO INVESTIGATE THE COMPLAINT FOR THE MEMBER?TRUE OR FALSE?

FALSE

400

WHAT ARE THE TYPE OF PRE SERVICE MIODS?

OUT OF NETWORK PROVIDER REQUESTS

NON COVERED BENEFIT

BENEFIT EXCEEDS LIMIT OR RESTRICTION

BENEFIT REQUIRES PA OR CLINICAL REVIEW

REQUEST TO CONFIRM COVERAGE IN WRITING


400

NAME 4 OUT OF THE 6 QUALIFICATIONS FOR RX AUTHORIZATION REQUREMENTS

STEP THERAPY

QUANITY LIMIT

FORMULARY

PA

B VS D

MEDICARE EXCLUDED

400

A MEMBER CANNOT FILE A GRIEVANCE FOR THIS ONE BENEFIT. WHAT IS IT?

NON MEDICARE BENEFITS

Medicare Excluded Medications

Medicare excluded/Not Part D Eligible Medications include:

  • Medications used for treatment of sexual or erectile dysfunction
  • Medications used for anorexia, weight loss, or weight gain
  • Medications used for cosmetic purposes or hair growth.
  • Drugs used for the relief of cough or cold symptoms
  • Barbiturates.
    Exception: Covered under Part D when used in the treatment of epilepsy, cancer or chronic mental health disorders. Refer to RxWeb to see if the medication is covered and if any requirements are needed
  • Benzodiazepines.
    Exception: Some benzodiazepines will be covered under Part D. Refer to RxWeb to determine coverage and if any requirements are needed.
  • Blood glucose testing strips
  • Heparin and saline flushes
  • Over-the-counter smoking cessation drugs
  • Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations)
  • Drug Efficacy Study Implementation (DESI) Drugs. These are prescription drugs that are unapproved by the FDA
  • Most over-the-counter (OTC) medications
400

WHICH APPEAL REQUIRES QIO INFORMATION TO BE PROVIDED TO THE MEMBER?

FAST TRACK APPEALS

400

WHO DO YOU CONTACT TO WITHDRAW A QOC COMPLAINT?

EMAIL THE RESOLUTION SPECIALIST TEAM AT Validation Team 

  1. Include the following information in the email.

    Note: Advocates may copy and paste the below template into their email if desired.

    • Subject Line: Quality of Care Withdrawal Request
    • Member's name:
    • Member's ID:
    • Intent Number (S-Case):
    • Member is requesting withdrawal of their Quality of Care investigation
    • Details of withdrawal reason, if available.
      Example: Member called in after receiving the letter advising that the plan would investigate her Quality of Care event with Dr. John Smith. The member does not want this complaint investigated because she does not want this to affect her relationship with the doctor.

  2. Educate the member:

    • We will contact the investigation team and request withdrawal of their investigation.
    • The investigation may have already begun, but the current actions will end once the withdrawal request is received.
    • They will receive a letter from the plan advising them of the withdrawal.
      • Confirm/verify the member's address.

      • Attach a note to the Quality of Care intent indicating the member contacted the plan requesting a withdrawal of the plan's investigation.
500

HOW LONG DOES A MEMBER HAVE TO SEE AN ONN PROVIDER WITH AN APPROVED MIOD?

90 DAYS

500

WHO SHOULD INITIATE THE COVERAGE DETERMINATION FOR THE MEMBER? THE PROVIDERS OFFICE OR THE ADVOCATE?

THE ADVOCATE

500

IF A MEMEBER COMPLAINS THAT THEIR PROVIDER IS REFUSING TO WRITE A PRESCRIPTION, SHOULD THIS BE CLASSIFIED AS A PART C OR PART D?

Part C:

Since the member's complaint is regarding the provider refusing to write a script.

Note: Complaints about the inability to obtain prescription drugs usually fall under a Quality of Care complaint unless there is a specific policy against it.

Example: Member needs to be seen in person by the doctor in order for the prescription to be written or a maximum supply of opioids is met and a doctor cannot approve more.


500

WHAT IS A NOMNC LETTER?

NOTICE OF MEDICARE OF NON COVERAGE LETTER, DENIAL OF MEDICAL COVERAGE ONLY IN NURSING FACILITIES, SKILLED NURSING, HOME HEALTH, COMPREHENSIVE OUTPATIENT REHAB (CORF), REHAB. NOT EXHAUSTING BENEFITS, IT IS NO LONGER MEETING MEDICARE CRITERIA.

500

IF YOU ACCIDENTLY SELECT THE WRONG RADIAL BUTTON WHEN COMPLETING A QOC AND MARK IT AS A NON QOC GRIEVANCE, WHAT ARE YOUR STEPS TO CORRECT THE GRIEVANCE?

CANCEL OUT ORIGINAL GRIEVANCE IN HISTORY AND ATTACHMENTS BY ADDING A NOTE. CREATE A NEW GRIEVANCE BECAUSE WHEN YOU SELECT THE QOC RADIAL BUTTON THERE WILL BE SEVERAL BOXES THAT NEED TO BE COMPLETED, THAT DO NOT APPEAR IN A NORMAL NON QOC GRIEVANCE. THE GRIEVANCE WILL BE AN AUTO FAIL IF THE INFORMATION NEEDED IN THOSE BOXES ARE NOT COMPLETED.

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