SOP Related
If the agent states that the plan is secondary and benefits cannot be provided, what should be the next step?
Mark drug as non covered and GE the call
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan
Prior Authorization
If agent say Predetermination is not required but it's optional, what should we need to enter?
We can input Predetermination as "available" don't need to PB
Which country recently hosted the 2024 Summer Olympics?
France
If the agent provides a generic copay of $65, what should be the next step?
Need to PB "Can I please have the costshare for brand?" because we always want brand costshares and not generic.
A process that determines which insurance plan is responsible for paying for a patient's medical expenses when they have more than one health insurance plan.
Coordination of benefits (COB)
Agent stated that the plan is a commercial plan but provide deductible 590 and OOP as 2000
OP should have PB "Is this Medicare, Medicaid or Tricare?" as per line 240.
Which country recently passed legislation to regulate AI development and use, aiming for greater transparency and ethical standards?
In early 2025, the European Union (EU) passed groundbreaking legislation to regulate AI development and use, known as the AI Act. This regulation aims to ensure greater transparency, accountability, and ethical standards in AI systems across Europe.
If the agent says the member is responsible for 100%, what should we input in the cost share field?
Mark "YES" to coinsurance, enter 100.
A treatment approach that requires patients to try less expensive medications before moving on to more expensive ones
Step Therapy
If the payer is Tricare for Life and the organization is Argenx, and the agent says they can't provide any benefit information, we need to collect the information from the IVR. What should we do next?
We need to mention that we are calling for PA if agent still unable to proceed then we need to GE and process as all good.
Which U.S. state recently made headlines with new healthcare reforms aimed at improving accessibility and affordability?
In 2025, California made headlines with new healthcare reforms aimed at improving accessibility and affordability.
If the agent states that the plan is a workers' comp plan, what are the next steps?
Is there another active plan on file?
If Yes: Collect benefits for the active plan.
If No:Mark Not covered & Gracefully Exit Call
A system of numeric codes that identify medical procedures and services.
Current Procedural Terminology (CPT) codes
If the IVR pulls up the member account but the agent couldn't locate it using the three pieces of information, are we okay to process it as a fail?
No because as per our new update if IVR locate patient then we need to try again for a better agent.
Which Indian company recently became the first to achieve a significant milestone in the electric vehicle (EV) market in 2025?
In 2025, Tata Motors became the first Indian company to achieve a significant milestone in the electric vehicle (EV) market. The company reached the landmark of selling 1 million electric vehicles, making it a leader in India’s transition to sustainable mobility.
If the agent provides the same cost share for a 30-day and 90-day supply, what PB is needed?
As per QA line 143 we don't need to PB
Federal law that sets a national standard to protect medical records and other personal health information.
Health Insurance Portability and Accountability Act (HIPAA)
If individual OOP is met but family OOP not met yet, should we need to PB about benefit before OOP met
True/False
True
Which company created the first video game console?
Magnavox (with the release of the Magnavox Odyssey in 1972).