HIPAA
If you receive a call from the health plan what pieces of information do you need to verify HIPAA?
Member name, member ID, and DOB
When member is showing as default payer, what are the steps to follow?
Check SQL, verify in correct CRM, verify we review for code/plan & state and case should be placed on hold(Request for additional info).
When do you use SQL?
Every call to make sure we are creating case in correct CRM.
Can a provider be update on an already approved case?
Yes, as long as the TIN # is the same and provider INN.
What is the TAT for a TX PSCR?
15CDs
How will you ensure you do not miss HIPAA when getting interrupted by the caller during the call?
Any answer is a great answer as long as HIPAA has been verified!!
When we receive an intake form and no clinicals are attached after making 1st attempt do we send to review?
No, you must make second attempt then send case to review
If you open up a case you must do what?
Put a phone note.
If MI case is changing setting from IP to OP & vise versa, what are next steps?
Create a new case.
Which LOBs and services do we handle Missouri Home State Health for Centene?
Commercial (Ambetter Solutions) Cardiac
Medicare Advantage (WellCare by AllWell) Cardiac
Commercial (Ambetter) Cardiac
Medicaid (Home State) Cardiac, ENT
If a provider office/facility can verify 3 pieces of information (name, DOB, and member ID), What can be used to substitute for the TIN/NPI for facility/practice?
Nothing, you need the TIN/NPI to verify HIPAA!
When an intake is completed over the phone and 1st attempt and 2nd attempt have been done but dx code is missing do we send case to review?
No, case is to be placed on hold until dx code is receieved
Caller calls for a status check & gives case # but not able completely verify HIPAA, you must do what to case? What is your call disposition?
Place phone note stating not able to HIPAA verify. Select case status.
When creating or updating provider or facility what are we verifying?
TIN & NPI match correct name and address.
Priority Health LOB Medicare what are the TATs for recons?
No recons.
When can we speak to someone one other than the member?
If member is under 18 or if member gives verbal consent.
Can you send case to review if case is sitting in draft?
No, please reach out to leadership as case may need to be recreated.
P2P queue is more than a three minute wait, what do we advise caller?
Advise caller there is a wait, I can leave you in their queue or I can gather your three best times & dates and send email to our P2P team.(let caller give their preference).
when making any changes to a MI case, who or what do we do for the information to be sent to HP?
Trigger 278 in phone note
What is the resubmission time frame for TX commericial?
180CDs (all plans are after appeal window has closed).
If caller is unable to verify HIPAA, can we give hints?
No, we advise no case on file.
If case is created via phone & caller does not have all the needed information to create case, can we create send to review or place on hold?
Neither, we will as caller to call us back when they have needed information.
What is the difference between an abusive caller & upset caller? How would you handle?
Abusive caller is a derogatory verbal exchange aimed at you. Upset caller is one who is upset, scared but nothing personally towards you. We follow abusive caller policy to try to defuse the situation or next steps on ending call(always let leadership know).
With upset callers we remain calm and polite so we can try to assist.
When PO returns, the nurses call about downgrading to OP, what are we labeling call note as?
Site of Steerage successfull.
Wellcare
? What is the LOB
? What are the services
? When can the submit for a retro
Medicare
MSK-AZ AR, Cardiac-NY
MSK with in 2 days, cardiac within 14 days