Confidentiality
The verification items needed when a provider calls
What is tax id number, member name, and member DOB.
What is True. All of our public programs plans require a PCP to be assigned on the account.
The benefit for a routine physical for an OHP member for 2018.
What is: PHYSICAL EXAMS ARE COVERED IN FULL ONCE EVERY 12 MONTHS, SERVICES MUST BE PROVIDED BY THE MEMBERS PCP
*IF VISIT INCLUDES LABS THEY WOULD ALSO BE COVERED WITH NO MEMBER RESPONSIBILITY
Is Dr. Nicole Trajano at Elam Young Pkwy par with member Brenda Adam's id: 100659070-00 plan?
What is yes
Provider is par with the MCAR network.
Customer service go into the facets to change address on file
Bonus: Where is this scenario in KMS?
What is no, customer service routed the request over to membership accounting
Addresses -> Scenarios -> Address change needed for member within our service area.
A mother of an OHP member can call to change PCP on account for 20 year old son
What is no, we can only change the PCP with the member or provider unless we have consent on file.
When do we make PCP assignments effective for Medicare members?
What is the first of the month.
The disclaimer quoted when giving benefits to members and provider.
What is "This not a guarantee of payment and all services are subject to medical necessity, eligibility at the time of service and cannot be cosmetic, experimental or investigational and are subject to plan exclusions."
Pull up member Kathleen Dagsland id: 112973248-00 account to find out if Dr. Janice Miller par with her plan on Barnes Rd Ste. 205
Provider is not par with any of our Medicare plans.
Can a member live out of our service area and stay on our plan and travel to participating providers within our service area.
What is no, a member is required to physically live within our service area to be enrolled in our plan.
The PHI that cannot be given to a provider.
What is disenrollment reason/inquiry, premium inquiry, and social security number
Bonus: We cannot change a Medicare member's PCP with a provider. Only the member can change the PCP on file.
If the member is needing an urgent referral or other extenuating circumstances please see KMS scenario: How to request a backdated PCP.
The benefit for a GYN Exam for a Medicare Extra +Rx member for 2018.
What is:
**QD
In-Network:
COVERED ONCE EVERY 24 MONTHS WITH NO MEMBER RESPONSIBILITY, SERVICES MUST BE PROVIDED BY A PAR PROVIDER, NO REFERRAL REQUIRED
*IF VISIT INCLUDES PREVENTIVE LABS AND/OR MAMMOGRAM, THEY WOULD ALSO BE COVERED WITH NO MEMBER RESPONSIBILITY
Pull up member 100878171-00 for Barbara Marsh and verify if Dr. Betsy McDowell par with plan at Liberty Street location.
What is yes, provider is par with the plan.
Bonus: Is provider par with Medicare Prime plan?
True or False: PHP uses the same network of providers for our OHP plan and our Medicare Advantage plans.
What is false. We use a different provider network for our Medicare prime plan verses our other Medicare plans and a completely different network for OHP.
Bonus: Can a provider be par with all three plans?
Yes absolutely but not all are a part of all three.
Type of consent on file for member Richard Pacholl id: 100232866-00 Richard Pacholl.
What is a power of attorney
Bonus: Is it a financial or full power of attorney?
What pieces of information need to be included in your CSI when changing a PCP.
What is:
Effective date of change
The benefit for general labs for a Medicare Choice +Rx member in 2018.
What is:
**QD
In Network:
$10 COPAY PER DAY FOR LABS WHEN ORDERED BY PCP OR SPECIALIST WITH WHOM THEY HAVE A REF. $15 OFV COPAY MAY APPLY WHEN PERFORMED BY PCP. $30 OFV COPAY MAY APPLY WHEN PERFORMED BY SPECIALIST.
Pull up member 100657934-00 for Sheila Paxton and see if Dr. Mary Ann Dunlap is par with the plan.
What is yes, provider is par with the Align plan.
True or False: We use the disclaimer for giving benefits for an OHP member?
What is False. We only quote the benefit disclaimer to Medicare members.
Jane Radtke is calling to get premium billing information for Kurt Radtke id: 112946378-00, does she have consent to speak to PHP?
What is yes, we have partial consent on file for Jane Radtke through 11/09/19. CONSENT NOT VALID FOR THE FOLLOWING: HIV/AIDS INFO, MENTAL HEALTH INFO, GENETIC TESTING INFO, DRUG/ALCOHOL INFO. We can speak about premiums.
Can a provider ever change a PCP for a member?
Providers can change the PCP for OHP members. Providers can NEVER change a PCP for a Medicare member.
The benefit for a prostate cancer screening in 2018 for a Medicare Prime +RX member.
What is:
**QD
Digital Rectal Exam:
In-Network:
EXAM IS COVERED IN FULL WHEN ORDERED BY PCP OR SPECIALIST WITH WHOM MBR HAS A REFERRAL AND PERFORMED AT A PAR FACILITY
PSA Lab Test:
In Network:
$15 COPAY PER DAY FOR LABS WHEN ORDERED BY PCP OR SPECIALIST WITH WHOM THEY HAVE A REF.
Pull up member 113116335-00 for Judith Bailey to see if Dr.Bettricia Otto podiatrist on Bond Ave is par with the plan.
Bonus: Can the member see this provider using OON benefits? Is that an option on her plan?
Yes, member has the Medicare Choice +Rx plan with in and oon benefits.
True or False: Providence offers Medicare Supplemental plans which are secondary to traditional Medicare.
What is False. Providence only offers Part C or Medicare Advantage plans which are Medicare replacement plans.