Situational Guidelines
What does it mean when you get a One Breath call?
A member has made a threat to harm themselves or others
What is the website to search for Behavior Health providers?
Live and Work Well
Which resource is available to help you determine the process for requesting fulfillment?
Member Materials OneSource
What index would you use for completing NBA's?
A4Me - Completing an NBA - KM1004549
Member has to go into a Skilled Nursing Facility, Do they have coverage? If so, How much?
Yes, up to 100 days at $0
If you think you notice elder abuse what is the number one thing you DO NOT want to do?
Do not place caller on hold
What Intent do you need to use for provider look-ups?
Search and Assign Provider
What is the TAT for replacement ID Cards?
Allow 7-10 business days for members to receive their replacement ID cards.
The A4ME model is designed to deliver a simpler more personal experience for our members. TRUE or FALSE
TRUE
Member needs to get blood work done, Will we cover it?
Yes, $0 copay
If a member doesn't want to be recorded on a call what happens next?
Empathize, try to provide education on recorded calls, then let caller know within hour a call they will get a non-recorded callback.
If a provider is IN network what may you see that identifies them as an in-network provider?
Contracted, Par, In-network, INN, Participating
Which intent in Maestro will you select to fulfill most types of standard material?
Member Materials
What are some examples of the Preventive Services NBA that you would see in a members account?
Annual Physical and Wellness Visit, Breast Cancer Screening, Colon Cancer Screening, Diabetic Eye Exam, House Calls
Member was just discharged from the hospital, do they have anything available to them?
28 meals via Mom's Meals, 12 one-way rides via Logisticare, and 6 hours in-home care via CareLinx up to 30 days after discharge
If a member calls in asking for a supervisor what is the first step you take in Maestro according to the JA?
Launch Complaints Appeals & Grievances intent
If a provider is NOT in network what may you see that identifies them as an out-of-network provider?
Non-Contracted, Non-Par, Out-of-network, OON, Non-Participating
Which request type would you choose to process standard fulfillment in Maestro?
PerformMaterialsFulfillment
Where can you find the reasons you would not present an NBA?
A4Me - Reasons to Not Present a NBA - KM1007458
Member is wondering if their plan has a deductible? If so, how much?
$150 medical deductible
If your call is disconnected what are the 2 AUX options available for you to aux into?
Project Aux, and Disconnected Callback Aux
What does HMO/PPO represents in regards to member plans? Do you need a referral to see a specialist?
HMO – Gatekeeper: A referral is required to see a specialist
PPO – Open Access: No referral is required to see a specialist
What intent would you use to send Provider Directory?
Member Materials
What are some examples of persuasive techniques?
"Now that we have your billing inquiry resolved, let's see how we can take advantage of your benefits…", "The next thing I am going to do for you is...", "Please hold while I reach out to Dr. Frank's office. This should take 2-3 minutes..."
Member found out they may need cataract surgery, Would their plan cover it?
Yes, Outpatient Surgery benefit. $50 Copay