Claims
What does EOB stand for?
Explanation of Benefits
Which tab do you use in Maestro to see notes from a previous call?
Recent interactions tab
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
Member wants to search for their own BH Providers online. List one website you can direct the member to.
Which system do you use to see status and details of an MIOD? (Member initated organization determination)
ICUE
Which intent in Maestro is used when researching a medical bill the member is recieving?
Review Medical Claims History Intent
Which Intent in Maestro do you use to update members 'About Me' section?
Update Member Profile Intent
Which intent do you use in Maestro to mail out an Authorized Representative Form to the member?
Member Materials Intent
Is there a copay for Dual plan members, for BH virtual visits?
No (Not at this time)
Which tab in Maestro do you use to see Rx Bin, Rx Group, & Rx PCN?
Plan Tab
Which deptartment do you call if you have a question about a pharmacy claim? (Give at least 1 of 2)
OptumRX Help Desk
NEST
Which intent in Maestro do you use to schedule YOURSELF a follow up?
Compassion Embrace Intent
Inbound member not IVR verified. Name 3 things that must be verified?
First & Last name-MUST
DOB-MUST
Any One of the following: (Will accept any of these named)
Member is requesting plan to pay for a non-covered treatment/service from a specific BH provider. What should the agent submit?
MIOD (Member iniatied Organization Determintion, will accept OD)
Member calls in wanting a PCA (Personal Care Assistant) Home Health, if member is eligible, would this be a Medicare or Medicaid benefit?
Medicaid
Definiton:
List of medications approved by the members insurance.
Formulary
After sending SDOH refferals to members who have unmet needs, what else needs to be done to ensure UHC is following up to make sure members needs are met?
Send the Navigator a follow up. (Navplan)
Provider calls in, without the member, IVR shows member info & verified, provider wants to know why the members claim denied. Can you assist the provider?
No
(transfer to provider line)
Member calls in stating he is really depressed. Which statement MUST be asked?
Are you concerned for your safety, hurting yourself, or someone else?
What is UHC's program called, where a Nurse Practioner comes out to the members house?
Housecalls Program
Definition:
Sometimes called suprise billing, is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services being charged and the amount the insurance pays.
Balance Billing
What is the TAT (turn around time) for mailing out replacement ID cards?
What is the TAT (turn around time) for mailing all other material?
TAT for IDs- 7-10 business days
TAT for all other material-10-13 business days
OUTBOUND CALL:
What do you need to say if the member does not want to HIPAA verify? (Assuming you have explained why we have to legally verify HIPAA)
Ask the person to have the member call back at the phone number on the back of their ID card (or the appropriate callback number) during business hours.
Member states they are going to harm themselves or someone else, which SOP do you use?
Crisis Intervention Behavioral Health SOP
If the caller needs a copy of a CMS publication, form, or the Medicare & You booklet, Which SOP would you use & what are the steps you would take?
SOP: Appropriate Refferrals to Medicare
Use Perform Materials Fulfillment Request Type and Materials Requested Through Not Available dropdowns in Send non-marketing materials.