Compliance
A Verbal Grievance
What is it called when a member complains
When a members Medicare and Medicaid are both with UHC thier plan is _____
Aligned
My member recieved a bill and gave me the date of service. I go to this intent to assist and document this issue.
What is Review Medical Claim History
Mbr wants to set up home delivery for their medications. What do i do next?
What is Call over to Optum home delivery in Genesys, Warm transfer.
MIOD
When a member wants to request for a non covered service to be covered under part C benefits
What are the three categories for Medicaid eligibility according to the DSNP Toolbox chart?
Full, QMB Only, Partial
I would only do this when i am unable to resolve the members issue fully and it will require a follow up later than 48 hours.
What is sending a Navplan
Where i go to find out if a specific medication is covered..........extra points for the names of the systems.
What is a Formulary
Rxweb
CommunityPlan
Here i can find detailed information and a breakdown of specific plan benefits, i can ctrl F search to more quickly find specific words.
What is the Evidence of Coverage
Members must submit this request in writing to the plan, we only use the CAG intent for documentation of the call.
What is a Post Service Appeal
When we assist unaligned members by calling over to their Medicaid MCO and either warm confrenceing or warm transfering
What is the Final Rule
The Scripted intents that I am to go through with my member that represent gaps in care and identify life-saving opportunities which enable us to connect members with screenings and other preventative services
Mbr called in and said that she got a denial for her PA for a medication she is needing. What is the name of the system we look for Part D Prior Authorizations.
PAS
Primary Care Dr's, Specialist, and all Dentists can be found here by seaching the members zipcode.
What is Rally
A member missed their Dr appt due to transportation not picking them up. What type of complaint is this.
What is a QOC
How long is the members Grace period once they are disenrolled from medicaid
(how long do they have to re-enroll before they become eneligible for a DSNP plan)
What is 6 months
Mbr already has a provider and i am just assisting in making an appointment for them. What intent am i going to use.
What is Schedule Appointment
First fill for this type of medication has a 7 day limit. After that it can be filled at 30 day supply only.
What is an opioid.
The system i will use to find a members LIS coverage, Plan contract number, or other state information, but i use the Macro and send a teams message to get the information sent to me,
What is Marx
Unauthorized callers are able to submit only certain types of compliace cases without permission from the member.
What are QOC, Expedited Appeals, Sales Grievances, and Fast Track Appeals
For demographic changes i can make temporary changes in Maestro but for the permanent changes i need to direct the member to call ____ for Ohio, and _____ for MI.
ODJFS (Ohio Dept of Job and Family Services)
Michigian Medicaid Helpline
Under this Intent i can find a brief summary of all the members plan benefits. And it is where i will go to document any mbr interaction about benefits discussed. (Don't forget the drop downs!)
What Is Review Medical Benefits Intent
Coverage Determination
Submitting a CD Request
Here i can only view and not document, but i go here to find if the members has any prior authorizations or see if a member has been in the hospital.
What is ICUE