Show:
Documentation
HIPAA
Compassion
Claims
Pharmacy
100

What are the 3 standard documentation requirements? 

Always document details to describe the Who, What, and Where of each call.

100

What Must be Authenticated when a Provider calls regarding a claim?

  • Member information: First and last name
  • Caller information:
    • Caller's first name and last initial (e.g., John D.)
    • One of the following:
      • Provider tax ID number (TIN)
      • NPI/NCPDP number (also known as NABP#)
      • Provider's first and last name
      • Name of facility
    • Date of service
100

What are the 3 pillars for Embracing the Gray?

Recognizing, Acknowledge and Respond 

( Go to JA and Review KM1013755)

100

True or False? 

Member Medical Claim information can be accessed online if the member has registered their account on their plan website.


True

100

What are the four stages?


Deductible

Initial stage 

Coverage stage

Catastrophic stage

200

True or False?

Per the System Documentation JA, for any inquiry that involves more than one claim and/or more than one skill (e.g., hospital/physician), document all in ONE intent to be addressed as a whole for the member.


True

200

What Can Be Discussed After Authentication?

Only information directly relevant to the caller’s involvement with member’s care or payment related to member’s care should be disclosed. Like

  • Basic plan
  • Member claims (including prior authorizations)
  • Member enrollment
  • Member medical
  • Member sensitive
    Exception: Cannot be discussed with pharmacies
  • If requested, provider member's member ID.
  • If requested, verify member's demographics.
  • If requested by facility (e.g., hospital, skilled nursing facility, etc.), provide member's Medicare number (MBI).
200

Give me 2 compassion transitional phrases 

I can not imagine what you are going through

that is a great question lets check into it 

I see why you would be concerned, I can help

 that must be really frustrating for you 

(KM1220250 CAHPS Phrases and Compassion)

200

True or False? In-Network providers are not allowed to bill members for cost share above what the plan allows?

True

(JA KM1004873)


200

If a member calls in wanting to know what their copay is on a Generic Medication and has LIS Level 2 what would you quote them 

$1.55 


300

When reaching out to a Pharmacy regarding a denied medication, what needs to be documented?

Medication name and strength Pharmacy name pharmacy phone number who they spoke with and the outcome of the call 

300

When leaving a message to a member what may and may not be included?

Message may include:

Your name

The first or last name of the member

  • A call back number or instructions for calling back
  • Statement you are returning their call (if applicable)

  • Message may not include:
    • The full name of the member
    • Any health plan information
    • Member specific information
300

A member's wife calls in to report his passing, besides I am sorry for your loss what else might you say to show compassion?

  • "I don't know how you feel, but I am here to help in any way I can."
  • "You and your family will be in my thoughts."
  • "We are always just a phone call away."
300

Member is part of a Value Based Care Medical Group, should you use the PCD (pending claims detail) search to locate for the claim ?

You do not use PCD searches for these members.

JA (KM1788313)


300

When looking up a medication claim you see rejection code 33, what does this mean? And what should the Pharmacy do?

Missing/Invalid RX Origin Code; contact pharmacy to enter origin code and reprocess the claim. 

Contact the pharmacy to enter the origin code for the prescription.

Ask the pharmacy to reprocess the claim.

  

400

For Fraud, Waste and Abuse, what needs to reflect on the documentation?

  • Explanation of the potential Fraud or Abuse issue:
    • Who is the alleged suspect (Member, Pharmacy, Physician, Broker, etc.)?
    • What happened?
    • Where did this happen?
    • When did this happen?
  • Your findings regarding the concerns.
  • Actions taken.
  • Any next steps provided to the caller.
  • How the tip was submitted:

 

 

400

member calls in to add their best friend John as an Authorized representative, are you able to ?

No ( only Family Members)

KM1007874 JA  HIPAA definitions

400

Finish this sentence ( We are united hand...)

in hand with our members 

(JA KM1386659)

400

Member visited their provider to pick up a DME item. No claim has been received and the providers office is requiring the member to pay $200.00 upfront, is this allowed? What JA would you reference to assist with this scenario?

Claims Inquiry - Early Billing KM1007707

400

 What is the copay range for New York members that qualify for the EPIC program?

$3.00-$20.00

500

If a member hung up while you are reaching out to a provider, and there is not a valid phone number listed on the member account what should we document in the file? 

Call disconnected prior to resolution being provided to the member. No phone number available on the account or the phone number on the account was invalid. Outbound call could not be completed.

500

A firefly representative calls to get a new ID card mailed out to the mbr?

Yes

500

Name 3 note options for the compassion note in Maestro?

  • Life Navigator
  • Living Status (Lives alone, lives with family, etc.)
  • Communication Limitations (Blind, deaf, unable to read/write, etc.)
  • Transportation Assistance (Always/Seldom/Occasionally requires transportation to medical visits)
  • Recent Loss (i.e. recent loss of Family member/pet/friend, etc.)
  •  (JA KM1005711)
500

Texas member is enrolled in plan H0609-051, with Medicaid coverage SLMB Plus. Who is responsible for processing Medicaid portion? Why?

The provider will bill Medicaid directly. 

PBP 051 is not in scope for the cost share program.

(JA DSNP Cost share KM1014565 and then KM1007236)


500

The member is currently in the coverage gap, and has $100.00 left until they meet the TROOP. The full cost of their medication is $563.75. What would be the members responsibility? 

They will only be paying $100.00 because once the TROOP is met the member goes into the Catastrophic Stage where the member has no cost share.