Compliance
How do members submit POST Service Appeals (no disability)
In writting
Can a Broker/Agent change a members address without them being on the phone call?
Yes with a verbal attestment
What are the transportation benefits for each of the Ohio plans? Ride number and distance limit.
60 rides -- 75 miles
Member has NO claims on file for the date of service/provider name/and cost that they are receiving a bill for. What is likely the issue in this scenario?
Did not present ID cards/insurance was not ran by provider to pay for service
Where can I check for Prior Authorizations?
PAS, RxClaims, ICUE, Maestro tiles
The member wants to have a prescription filled for Vitamin D, they are getting a rejection from the pharmacy. What is the most likley reason for the rejection?
Medicare Excluded - Not Part D Eligible
Can an authorized representative file a standard verbal grievance?
Without permission, no. With permission of the member, yes.
Are braces/orthodontics covered for any of your plans?
No
Member has received a letter that say's "this is not a bill" however, it states the member has a liability of $20 for co-insurance. Does the member owe this? If not, what has the member received?
We would have to check the claim under the Caid timeline. Member has received an EOB
How can I send a POA form to the member?
Maestro >> Member Materials intent
Member states they filed a Grievance last week and they were told they were going to get a letter regarding the outcome. Is that something we do/send?
No, they were told incorrectly. Apologized and advise that Grievances are an internal investigation and we do not send letters regarding the outcome
What must be authenticated for a Guardian listed on the members account?
Member name, DOB, and one piece of personal info + the callers name and relationship to the member
For EACH of your plans, please tell me the max coverage (cost wise) the members have for Routine Dental Services
Check each plan, they will vary
Member has QI level Medicaid, we see that the claim has been processed under their Care and Caid. But the member owes $3 for their co-pay. Are they responsible for this bill?
Yes
Member has submitted a request for a non-fomulary exception, where can we find the status of their request?
PAS / RxClaims
Member states they went to their providers office last week and they were upset because the providers office had blood on the floor and was overall VERY dirty. What kind of Grievance is this?
QOC
What are the three steps we complete if the Authorization is NOT on file for a Guardian/POA
1. Advise caller that they are not listed, 2. offer to send form, 3. provide correspondence address
Who is the Vendor for Routine Vision for H5253-059 -000
MarchVision
What are the two timelines we have to check to ensure the DSNP members' insurance plans have been ran?
Care and Caid
If the member is getting a denial for a medication at the pharmacy, where can I locate the rejection reason?
Maestro >> Pharmacy Claim History
Member wants to file a prior authorization, what do we do?
Trick question, is it part C or D?
If I do not have the member ID, what else can I search with in Maestro?
Name, DOB, and verify a third piece of information
Under H5322-028 -000 -- how many meals/duration of time can the member receive meals home delivered to them after being discharged from a SNF/In Patient Hospital stay?
Up to 42 meals for 21 days, delivered one time per year after an inpatient hospital stay to maintain nutrition
180 days
What system do we use to locate the vendor information for ancillary benefits?
Wellness Lookup