Benefits and Coverage
Does CGM require PA?
Yes, Prior authorization is required from the vendor in order to obtain a CGM whether covered under pharmacy or medical benefit.
SOT: Benefits & Coverage Advocacy- Diabetes, CGM Diabetes (uhc.com)
What are the two pre-requisite requirements for BRCA testing?
1) You must receive genetic counseling prior to having BRCA testing. 2) Proof of completion of genetic counseling must be included with notification request.
SOT: Notification Advocacy -> Initial Process -> Breast Cancer & Genetic Testing
Is Orthopedic health support a program referral or a call one? After that is determined what are the steps to documenting in icue?
OHS is a program referral not a call one. Documentation is completed under "New Program Documentation".
SOT: A4me Tier 3 Clinical Process > Orthopedic Health Support
Who is Eligible for Medicare?
Age 65 or older, Disability, End- stage renal disease (ESRD)
SOT: Eligibility Advocacy > Medicare + > Medicare Entitlement & Updating > General Medicare eligibility
What are the qualifying conditions for a Transition of Care/Continuation of Care?
Non-surgical treatment for cancer; treatment for symptomatic AIDS; treatment for severe ESRD; treatment and follow-up for a serious acute condition such as heart attacks, strokes, and recent major surgeries
SOT: Benefits and Coverage Advocacy SPA
What is the Gold Card Program and which SOP is used to find information about it?
Allows qualified providers that have consistently demonstrated adherence to evidence-based guidelines to render certain medical, behavioral, and mental health services, that would otherwise require a Prior Authorization, with only an Advanced Notification or exemption where required by state regulations.
SOT: Notification Advocacy > Gold Card FAQs (uhc.com)
Member calls in and you notice GERD on their dashboard. They start talking about going to see an ENT because the have had so many sinus issues and want to see a specialist, what is priority for us to address?
Trigger words are always priority!
SOT: A4me Tier 3 Clinical Process > Identify Member Opportunities
If a MBR has himself and his spouse covered under his insurance with this employer and the wife has insurance for them both under her employer, who is primary for whom?
The husbands plan will be primary for him, and the spouse plan will be secondary, For the Spouse, their plan will be primary and his plan will be secondary for her. The employe of the employee is primary.
SOT: Eligibility Advocacy> & rules of COB > Rule one, Non-dependent/Dependent
How do we determine if a member has travel and lodging benefits for their condition/situation?
Locate coverage in AVA/IBAAG and follow other applicable steps in SPA.
SOT: Benefits & Coverage SPA > Travel and Lodging > Medical Travel and Lodging tab
Why do some providers and/or services require authorizations while others do not?
Some states recently passed a gold carding law that allows health plans to exempt some providers from having to submit authorizations for services where we consistently approve their preauthorization requests, so by law those providers cannot submit authorizations for the services they request where they have received this gold carding exemption.
When should the PHS portal should offered?
On all Call One where you find the member is eligible for PHS website.
SOT: A4me Tier 3 Clinical Process > Call One > Offer PHS 3.0 Digital
Which department do we transfer to if the member ask about private plans?
UH One formerly Golden Rule.
SOT: Eligibility Advocacy > Continuation of Coverage
Can a member call in for a gap exception request if their policy is fully insured (FI)?
No – Inn provider must call to request an exception.
SOT: Benefits & Coverage SPA > Network Gap exceptions > Managed Care tab > Step 3
Can I see which providers are gold carded?
Not at this time.
Where do you find if the member is eligible for PHS website?
PHS will be listed as a program on the Dashboard to determine eligibility. Also will be listed in ICUE on the left menu after you have accepted the Call One Program. Also listed under "New Program Documentation".
SOT: A4me Tier 3 Clinical Process > Call One > Offer PHS 3.0 Digital
What can waive the maximum age and/or full-time student requirement to continue coverage as a dependent?
Handicapped child status.
SOT: Eligibility Advocacy > Dependents >Handicapped Child