Overview
How many Regions is Virginia Divided into?
Six Regions: Central, Northern/Winchester, Roanoke/Alleghany, Southwest, Tidewater & Western/Charlottesville
VA's Cardinal Care Managed Care Program is specifically designed for the fee-for-service and managed care mbrs who are enrolled in which programs? *****
1. Medallion 4.0,
2. Commonwealth Coordinated Care Plus (CCC Plus)
3. Family Access to Medical Insurance Security (FAMIS)
HEALTHY BENEFITS PLUS APP/ WEBSITE
What system can be used to view RX Authorization requests *****
PromptPA ****
(However, per recent updates RX Auths can no longer be viewed in PromptPA & can viewed in PA Hub)
There's situations in which a provider is allowed to balance bill a member. TRUE OR FALSE
TRUE
What's the name of the Virginia's Medicaid Program?
Cardinal Care
When speaking to members, it's okay to use the terms "aligned" and "unaligned" when discussing coverage or benefits? TRUE OR FALSE?
All DSNP mbrs are automatically enrolled in the Healthy Options Allowance Benefit. True or False
With regard to Pharmacy PAs, an auth is automatically aborted after how many days? ****
Three
TRUE.
1. HHH of Virginia (MCD only)
2. ALIGNED= Humana MCD + H2875-001 or H2875-003 (with aligned indicator in CRM)=
3. Humana MCD + Humana Medicare plan (Unaligned plan)= for MCD plan questions only
4. Humana MCD + Medicare plan with another carrier (Unaligned)= for MCD plan questions only.
When making demographic updates to mbr's phone number or address, who else needs to be notified?
1. Food
2. Admission to personal enrichment activities (museums/concerts, etc)
3. Pet supplies
4. Assistive Devices
Food, Pet Supplies & Assistive Devices
What's included in the Smart Summary document?
1. Progress towards deductible
2. Overview of claim activitity for prev. month
3. Information on mbr rights
FALSE.
Which webiste is referenced to as the main site to direct prospective MCD members for info?
Virginia Medicaid website: www.dmas.virginia.gov
When there's a provider termination from Humana's network that impacts MEDICAID members, which process is followed?
CONTINUITY OF CARE
There's 28 Activites that HHH in VA members (MCD only) can complete for rewards as part of what program?
Go365
Which system do we use to check RX Claims?
Which system do we use to lookup RX alternatives/pricing?
RxNova
ConnectPro
If caller requests to speak directly to Care Manager, we can transfer their phone call. TRUE OR FALSE
TRUE. Call would be transferred to Care Management support extension (VA MCD Phone#s)
Some VA Members may have/be eligible LTSS waiver services. True or False?
TRUE. We'd check LTSS indicator in Eligibility section on Plan Member page in CRM.
**Important: Not all mbrs who are entitled to waivers will have a Yes or No in LTSS indicator field.
Check Debut to verify which, if any waivers mbr has. (Debut will only display waivers mbr is eligible for)
Which of these is a MEDICARE term that's used when a member has an active treatment plan for a specific situation and impacts new enrollees to a plan?
TRANSITION OF CARE
Which is NOT an eligible Go365 activity for HHH VA mbrs?
1. Covid-19 Vaccination
2. Diabetic HbA1c screening
3. MCD Mbr Health Screening (MMHS) completion
4. CPR certification
CPR Certification
If mbr is a VA Aligned mbr, and they have questions/issues with RXs-- In RXNova, which Customer# dropdown would we use to access RX claims for mbr? (0319 or 0320)
We'd check under
0320- Humana Medicare first, then if claim/Rx isn't found we would then check under
0319 - Humana (Medicaid)
What STATE system is used to verify mbr's VA Medicaid eligibility?
MES (Medicaid Enterprise System)