Third Party Callers
What information are you allowed to give a third party caller if they are NOT authorized to speak on an account
Formulary
Provider/Pharmacy network information
Plan Cost Information
What is Marketing Misrepresentation
Marketing Misrepresentation is when a new or existing member calls customer service may indicate that they have been misinformed, misled, or misrepresented by a Sales Agent or Broker.
When each month are premium payments due
the 20th of each month
What does CIT stand for?
Claims Inquiry Tool
How long is a POA good for on a member's account
How long is a AOR good for on a member's account
Their is no expiration for a POA -The only way a POA will expire is if updated paperwork has been sent in in regards to the change of POA status and a new POA has been appointed
AOR is good for one year after this year the member must fill out another AOR form for the third party to be able to remain on the account
What are some keywords that could identify marketing misrepresentation
I was not informed
Nobody told me that
I was told differently
I did not enroll
I was told that my insurance changed to WellCare I was not aware
They said this was the copay, I was told differently
This benefit was not explained to me
The Billing cycle begins what day each month
the 5th
The CIT is a web-based tool that allows the user to view the claim lines on which iHT has appled a payment policy The CIT also provides a comprehensive explanation of the payment policies that were applied
What 3 things can you provide a third party caller NOT listed on the account if they have questions about a member's Formulary
What drugs are or are not covered
Drug tiers level and any applicable restrictions
Drug copays (assuming no LIS)
Should a grievance be filed if a member calls in about Marketing misrepresentation
Yes a grievance should be filed on the member's behalf.
*Make sure you get permission to file the grievance
True or False: Member's who use online bill payment will receive a coupon book in the mail.
True- They will receive a bill coupon book for their records. These coupons will include a note saying that they do not need to send payment
Who may call in asking about claims
Providers and members who have received a bill in the mail
What are the names of authorized users that you can share information with if listed on the member's account?
POA- Power of Attorney
AOR- Authorized Representative
Legal Guardian
Where can you find the enrollment source in Care Connects
Under the Eligibilty tab
If a member calls in and says they need a new coupon book where will you go to order a new coupon book for the member
Material Request
Does CIT provide an explanation of why a claim was denied or changed?
Yes- the script and rationale are tools designed to assist you in handling claim inquiries. The script provides a basic explanation of why a claim was denied or changed.
If a third party caller not listed as an authorized user states they are the member's POA but you don't have that information on file where do you tell them to send the POA paperwork to
WellCare Health Plans
P.O. Box 31372
Tampa, FL 33631
or they can fax it to 813-464-8413
What are the 6 different Enrollment sources you could see in Care Connects to know how a member was enrolled
A- Auto Enrolled by CMS
B or a blank field- Beneficiary Election
C- Facillitated Enrollment by CMS
D- CMS annual rollover
H-CMS or Plan Reassignment
K- CMS submitted passive Enrollment
Can a member pay for their own and their spouses premium with one check
Yes one check may be issued for both the member and their spouse. However, both coupons must be included in the envelope. Make sure both of the member's id numbers are on the check.
What information do you need when looking up a claim in Care Connects
Date of service
Billed amount
Provider
Claim number (if the member has it)