DSNP
What is the grace period members have to renew/recertify Medicaid?
6 months
If a members account is termed, what can we do to assist the member?
Advise the member to call the state to renew/recertify and provide the number 855-259-0701, also offering to transfer.
Define LTSS CHOICES eligibility.
Live in the state of Tennessee.
Must be 65 years of age or older or an adult with a physical disability.
Medicaid eligible.
Meet Medicaid criteria for payment of Level 1 (see below) nursing home care.
Have a safe home where one can receive HCBS.
Be able to get services in the community at a cost less than that of nursing facility.
Who is our dedicated incontinence supplier? Where can I find this information?
Edgepark. R.E.A.D One Pager.
When you get a call from a member and they are calling to check their balance, which intent can you document under? Are you including the balance you provided them in your documentation? What else are you providing the member when they call about their balance?
Review Medical Benefits intent, under value added services or the plan tab and selecting Ucard. Document the balance you provided them, also provide them with the Ucard balance IVR phone number 833-216-6708
What are the restricted items members can not purchase with Rewards?
Alcohol, tobacco, lottery tickets, firearms, cash conversions (gift cards, etc.) Utilities, Medicare covered expenses such as copay costs and medical costs, Rx copays.
Can we change the members address on their account?
Yes, temporarily (30 days). Member would need to permanently change their address with the state.
Define ECF CHOICES eligibility.
Who is our Transportation Vendor? What is their phone number?
Tennessee Carriers. 866-405-0238.
When members are calling about their dental benefits and needing to find a dentist, which intent are you documenting under and what are you documenting?
Review Medical Benefits, dental.
What systems/resources can we use to find a members MCO?
MARx, ICUE, GPS
Are Medicaid members required to get a referral from their PCP to see a specialist?
Yes. Medicaid members must have a referral to see specialists.
If a member is ALIGNED, what are the things we must confirm to determine you can do a CHOICES referral for the member?
Active Medicaid, If they are not already enrolled in CHOICES, a referral on file that has been rejected/denied over 30 days.
What are 5 qualifying chronic conditions listed on the Additional Benefits Verification Form that members must get their PCP to fill out and send back to us in order to receive Healthy Food benefits?
When members are calling to find out what immunizations are covered under their plan, which intent are you documenting under for both DSNP and Medicaid?
DSNP: Review Medical Benefits, Vaccine/Immunization
Medicaid: View Member Benefits, Immunizations/EPSDT
Can we change a DSNP members permanent address? What intent do we use in Maestro?
Yes. Update Member Address Intent.
If a member calls because their claims are denying, what is the first thing we need to look for that's listed on a members account?
A primary insurance (COB)
If a member is UNALIGNED, can we do a CHOICES referral for the member?
No. The members MCO must do the referral.
What is the standard TAT for prior authorizations? What is the expedited TAT for prior authorizations? Where do we go to locate prior authorizations?
14 calendar days, 72 hours, ICUE
When a member calls to change/assign a PCP, which intent are you using? What do you need to confirm before assigning the PCP for Medicaid and DSNP members? What do you need to ask the member before reaching out to the PCP?
Search and Assign Provider intent.
Confirm INN status with their plan, if DSNP, confirm they are INN with their MCO if they are not aligned.
Accepting new patients.
Offer to schedule an appointment that is based off members convenience.
Are referrals from a members PCP required for DSNP members to see a specialist?
No, DSNP members are not required to have a referral from their PCP to see a specialist.
What are three Added Value Benefits?
Healthy First Steps, Nurseline, Blood Pressure Monitoring, Smoking Cessation, Weight Management, Health Coaching, Baby Scripts.
SOP: KM1902808
What are the three groups for the CHOICES program and who determines what group the member may fall under?
Group 1: Persons of any age receiving Medicaid reimbursed care living in a nursing home.
Group 2: Persons age 65 and older and adults 21 and older with physical disabilities who meet nursing home level of care but choose to live at home and receive home and community-based services.
Group 3: Group 3 is intended for persons age 65 and older, and adults 21 and older, with physical disabilities who are at-risk of nursing facility care. To qualify for Group 3, individuals must receive SSI (Supplemental Security Income) payments from the Social Security Administration.
How do DME prior authorizations process?
Which intent do you use to send emails/forms for DSNP members?
Which intent do you use send a member a Ucard?
Which intent do you use to discuss changes of members plan benefits for the upcoming year?
Which intent do you use when doing NBA's?
Send informative Message intent, Member Materials intent, ANOC Changes intent, NBA's create their own intents.