Explain it
Why do I have to pay a copay, I thought I was covered for my services.
You may be covered, however you are still responsible for a cost -share as per Medicare guidelines
How much do members pay for drugs during Donut Hole?
25%
Where can you check the member's OOP MAx and deductible for medical services?
Review medical benefits - Plan level liabilities
How does OTC benefit work in M&R?
- Quarterly credit, not to pay bills or buy food
What is the timeframe for a provider to submit a claim ?
- There's not a standard timeframe, it depends on the division.
What is national provider network?
It means that you can receive services out of your state of residence
LIs has levels, member pays depending on his LIS level. It pays premium and drug cost
Where can you check if a member is able to see doctors out of area?
-Review medical benefits - Plan info
- Review medical benefits - Passport
If a plan says " Network Type" Gatekeeper . What does it mean ?
Member doesn't need a referral for specialist visits
If claim status is pending, what can you tell the member?
- It takes 30-60 calendar days to be processed since the entered date
I received a letter saying that I will have a LEP. What's that?
- A Medicare penalty that is giving to members that did not have a part D plan for more than 63 days after their Medicare eligibility date
What is a crossover claim?
Its the refill in which members switch from one stage to another
How can we process a credit card payment if not on file?
- Genesys/ Semafone
IF a member needs a knee infiltration. Is this covered? how would you confirm coverage and what's the benefit?
- Part B drug
If a member calls about a bill received a bill from a service provided at a mental facility, where can we see the claim?
We can't, we must transfer to Behavioral
What is PMG ?
- Its a third party that works with UHC in order to process claims and authorizations as well to give a wide provider network to the members/ This wont affect your benefits/insurance
A member wants a 90 day supply for Danyelza. Is that possible? How can she get it? Is the medication covered? 004881030
Not possible as its a tier 5 drug, Drug is covered, Needs PA
What does the umbrella sign under the member's name mean?
- Member has Supplemental with UHC
What's the difference between Medicare covered Chiro and Routine Chiro?
- Medicare covered is in all plans, Routine not in all plans
- First one is to treat chronic low back pain, second one, for any kind of pain
If you cant find a claim in Maestro, what should you do before telling the member we haven't received it ?
Check if there's a PMG on the account and contact them
How do members go out of the Coverage Gap?
- By reaching the troop stablished by Medicare
Why members wont pay a single/same amount for drugs during the year?
Because all part D plans have stages, member pays different depending on the stage
In Maestro, how can we check the method of payment of the member?
- Manage payment/ General billing questions/ Summary
In Maestro how would you search if a biopsy is covered?
- Ask probing questions, type key word/ category - Outpatient surgery
937716211 For member Id, member received a NODP from DOS 01/12. What can you tell the member
- Claim is duplicated, original is already paid