HIPAA
Who is considered an Other Third-Party caller under HIPAA guidelines?
Other Third-Party callers include social workers (non-Optum employees/staff), transportation and OTC vendors, union benefit representatives, drug manufacturer assistance programs, state pharmaceutical assistance programs (in most states), and interpreters.
What effective date should members be aware of regarding the coverage for OneTouch meters and test strips?
Effective August 3, 2025, One Touch meters and test strips are no longer covered.
What types of interactions are included under the "Customer Service" grievance category?
The "Customer Service" category includes interactions with any call center, HouseCalls, provider office staff, hospital staff, facility staff, pharmacists, and pharmacy staff. It specifically relates to issues experienced when contacting the plan or interacting with plan representatives.
What type of issues might a caller present that would be considered an appeal?
A caller might present issues related to an adverse decision for a prior authorization, a claim, or a notice of discharge from an inpatient facility.
How many seconds should the advocate answer the call?
What must a sales agent provide to authenticate a member's information during a call?
The sales agent must provide the member's first and last name and any two of the following: Member ID, Medicare ID (last 4 digits only), Medicaid ID, permanent address, or date of birth.
What is the only exception for a member to receive more than a 30-day supply of medication?
The only exception is if the medication is in an unbreakable package.
What types of complaints are excluded from the "Customer Service" grievance category?
Excluded from this category are complaints relating to transportation issues and interactions with providers, dentists, or individuals responsible for providing medical care to a member. Such complaints should be directed to the appropriate categories.
What is the timeframe for submitting an appeal after an adverse decision is notified?
The timeframe for submitting an appeal is 65 days from the notification of the adverse decision.
How many points you would get by offering the SSO to the member?
5 points
Can an Authorized Representative submit a verbal grievance on behalf of a member without explicit permission?
No, Authorized Representatives cannot submit a verbal grievance, coverage determination, organization determination, or appeal for a member without specific permission from the member. Exceptions apply for sales grievances and pre-service appeals.
If a member has a 90-day supply of medication filled on July 1st but loses it on July 5th, what happens next?
The member may be granted a one-time exception for a refill, but they are still responsible for the cost of any medication needed until their next eligible refill date based on the original 90-day supply from July 1st.
If a member states, "I changed my provider but never received the updated ID card," what type of complaint does this fall under?
This complaint falls under the category of "they did not receive the requested materials," specifically regarding the updated ID card following a provider change.
What should be on file before submitting an appeal for a claim denial?
A denial must be on file prior to submitting an appeal, or the member must disagree with the processing or responsibility of the claim.
Where do we deduct the points if the advocate failed thank the member for authenticating the account through the IVR
Model/Client specific requirements (5 Points)
If a caller claims to be an Authorized Representative but their authority is not on file, what should the advocate do?
The advocate should advise the caller that no documentation reflecting their authority is on file and that legal documentation must be submitted to be recognized as an Authorized Representative. Additionally, they can offer the submission of an Authorization to Share Personal Health Information form.
How is the late enrollment penalty calculated?
The penalty amount is at least 1% of the base beneficiary premium (the national average premium) for each full uncovered month that someone was eligible to join a Medicare drug plan but did not enroll.
What complaint could a member have if they found that a particular retail store does not accept their OTC benefit?
The complaint would relate to "Over-the-Counter," indicating that a retail store does not participate with the OTC benefit, making it difficult for the member to access products.
How should advocates manage a situation when a member wants to change a previously submitted Standard Appeal to an Expedited Appeal?
Advocates should submit a new Expedited Appeal intent in Maestro for applicable plans, as this cannot be changed retroactively.
Wha should the advcate do if specific provider is identified and the customer indicates themselves or a covered dependent plan on seeing them in the future
The advocate must offer to assist in scheduling an appointment.
What actions are Authorized Representatives allowed to take regarding member account updates?
Authorized Representatives may update limited demographics such as language preference and member's phone number, change the method of payment from EFT or recurring credit card to billing statement with permission, and report member rewards. However, they cannot make any changes without the member’s consent if it's not specifically mentioned as permissible.
The penalty amount is at least 1% of the base beneficiary premium (the national average premium) for each full uncovered month that someone was eligible to join a Medicare drug plan but did not enroll.
Credible prescription drug coverage includes:
If a member experiences a delay in receiving their OTC items, what complaint category does this fall under?
This falls under the "Over-the-Counter" complaint category, specifically related to the OTC order taking too long to receive.
In what circumstances can a post-service appeal be expedited?
Post-service appeals (requests where the service has already been rendered) can never be expedited.
What do you call attribute when the advocate has access to information or systems to assist the customer but cannot solve on their own, the advocate must offer to reach out and collaborate with another party on the customer's behalf to resolve their need?
Perform Outreach