Miscellaneous
When receiving a CMS Test Call, what are the correct C/I
Other & Test Call
When updating a Primary Care Physician (PCP), and the member has a specific provider in mind, what do you do
Check the provider’s availability by performing a Physician Search within the PCP Change Template
A member is struggling with finding a Cardiologist that is in network. The member states they are having trouble with Humana.com and find it confusing.
Show empathy and offer to guide the member through the Find Care tool to help them understand how it works.
What Part B plans require accessing the referral guidance tool to verify if a referral is required
MER (HMO) and MRO (HMO-POS)
A member with an EyeMed Vision plan is calling regarding upcoming cataract surgery.
Provide the member with their surgery benefits via DEBUT
A member is due for a routine mammogram, but her doctor has recommended that she get a more advanced 3D scan.
Quote both Preventive Breast Cancer Screening and Diagnostic Mammography via DEBUT
Which tool is used to verify Provider contracts and network information if the accuracy of the Find Care results is called into question?
Provider at a Glance (PAAG)
Which of the following is NOT considered a Medicare covered dental service
Routine extractions
How do you handle calls regarding members asking about Gastric Bypass surgery for weight loss?
Advise that another area will assist them and transfer the caller to a dedicated associate for bariatric calls
What is a true statement in regards to medical supplies.
Supplies are disposable
You receive a call regarding plan type: MCD. What is your next step after authenticating the caller?
Offer the member the number to the Medicaid department and Consult transfer
A new ID card is automatically issued anytime a PCP is updated for members with which plan type?
HMO
What is is NOT an example of Durable Medical Equipment (DME)
Catheter
Which part of Medicare is a glucose meter covered under?
The member's Part B DME Medical benefit
The definition of a referral authorization is:
The process of obtaining a referral from the health plan for outpatient services provided outside the PCP`s office or network.
How do you schedule time to place an outbound return call to a member when needed?
Create a CRM Notification Task and route it based on Mentor’s guidance
When a hospital is in-network (INN) for a member’s plan, what does this mean for the physicians that practice at that location?
A separate physician search must occur to confirm
How are calls involving organ transplant benefits (i.e. heart, kidney, lung etc.) handled?
Warm transfer callers to the Transplant Management Team
A member is reporting an out-of-state address change effective immediately but also wants benefit information for a surgery that will occur in a few months.
Update the address and connect them to sales for a plan update in their new state at which time, we can provide benefit information under their new plan.
The definition of a preauthorization is
The process of obtaining certification from the health plan for inpatient or outpatient services. Often, clinical or medical appropriateness is reviewed against criteria and assignment of length of stay
What is the first course of action taken if you recive a phone call that is threating Humana?
Note as much information as possible and verbally notify leadership
Where will you access Find Care to answer Provider-related questions when the member has a plan with a future effective date?
How do you handle calls for members seeking to locate a counselor/therapist to receive mental health counseling for depression and anxiety?
Transfer the caller to the appropriate Behavioral Health vendor based on their plan's market
Where will you find MRI benefit information in DEBUT
Outpatient Advanced Imaging Services
What type of plan requires a referral
HMO