FOCUS
PERSEVERE
ACHIEVE
BONUS QUESTIONS😊
100
Is Auth history required for Upheld cases, true or false?
False
100
If cohere response email is missing, what question number should we down score under?
Q3.
100
UM market email is only needed for cohere cases once case is upheld. True/False.
False. It's not needed at all for cohere cases.
100
Where can we check citrix I.Ds for associates and nurses.
Go to Hi Humana site then select "workday"!
200
If EOC is unable to open what question number/s do we put technology down score under?
Q3 and Q4.
200
End dates in CGX should be left blank for all inpatient cases. True/false
False.
200
For DME purchase/rental we should always check the Provider's address to verify the state service was rendered in. True/False
False. we check the state the member resides.
200
Which question number does this down score affects. "Approved number of units not updated to reflect overturned unit as 1. Refer to CGX 2.0 Procedure-Updating an Outpatient Auth, step 13a.
Q6.
300
Which Inpatient service should have end date updated in CGX?
Inpatient Surgery.
300
If associate did not add effectuation dates in Determination letter for an outpatient service, do we down score?
No
300
JUST FOR BEING THIS AWESOME!!!
HOLD DIS...300 POINTS!!!
300
Provider Specialty is missing from subtask notes but is populated on RMD Form. What error code do we down score under?
Subtask documented incorrectly.
400
If Claim Payment note does not have the word "overturn" which word could be used to replace "overturn" for note to be acceptable.
Approved/Approval.
400
Contact Outcome for Resolution calls made to Provider should only be "Unable to reach" if call is not successful.
False! Resolution calls to the Provider should always be Notified of Resolution even when call is not successful. (All we need to see is an attempt to contact provider and that's good enough).
400
For Cohere cases, once the RAD is attached we don't need to have the cohere response email screenshot attached. True/false
False. This is needed once RAD was received.
500
Name the documents when missing affect Q5 for overturned cases (Final determination missing)
Approved auth, Auth history, UM/G&A email.
500
When 2 resolution letters (correct & incorrect) are sent, outreach should be made to whom and advising what?
To the recipient of the letter, advising they will receive 2 letters and that the 2nd letter is the correct one.
500
Once case is Cohere, should you always see the Business Partner Request and Business Partner Response case notes?
No. Sometimes no response has been received up to the time case is sent over for review. When this happens, you will only see the Business Partner Request case note.