This Should Be Covered! (CD&A)
The initial request when MED D Beneficiaries can ask the plan to cover medications not included on the formulary or drugs that are on the formulary but have predetermined criteria is called this
What is Coverage Determination?
Using these 3 pieces of information is the best way to locate a beneficiary's application in FAZAL.
What is Last Name, First Name and Date of Birth?
SRT should take over an Escalation or Procedural Request call within this timeframe
What is 2 minutes or less?
Before proceeding with a voluntary disenrollment request, this must first be verified.
What is verify if the beneficiary is currently active in Compass?
Before addressing any Premium Billing questions, or beginning any Premium Billing processes, the CCR must review the beneficiary’s Premium Billing Balance (if any). Where is this accessed in Compass?
What is click the Medicare D tab to access the Medicare D Landing Page. Then click the Premium Billing tab? (Click the chevron arrow to expand/collapse each section.)
If a Beneficiary disagrees with the plan's decision, there are _____ _____ of appeals available to try to obtain coverage of medications.
What are five (5) levels?
This is the column you look at to verify the beneficiary’s enrollment status.
What is the Record Stage column?
If the issue becomes complex, SRT should take over this call type within 5 minutes
What is Job Knowledge Assist?
CMS requires SilverScript to obtain all disenrollment requests in _____.
What is writing?
This website(s) cannot process EGWP (SSI or Aetna SSI) beneficiary payments or plan requests.
What is The SilverScript Member Portal, powered by InstaMed, and AetnaMedicare.com?
Before beginning the process or checking the status of a Coverage Determination or Redetermination, the CCRs MUST verify they are speaking to one of the following individuals:
What is:
Beneficiary
Authenticated SHIP Counselor
Physician or other Prescriber (includes representative of a prescriber's office or a representative of the prescriber)
Power of Attorney (POA) or Appointed Representative (AOR)
Legal Documentation MUST be viewable in Compass or FACETS to continue with the caller's request.
Pharmacy
The pharmacy can check the status of a Coverage Determination or Redetermination.
This is a Data Exchange (DEX) method code, used for any enrollments that come in from the web site on www.medicare.gov.
What is OEC - CMS Online Enrollment Center?
A comprehensive account review conducted to prevent member callbacks
What is 90-day Outlook?
These are the three (3) different methods to submit a written request for disenrollment by fax or mail to SilverScript.
What are: a) You can access aetnamedicare.com and download the form; b) I can request a form be sent to you or; c) You can submit a handwritten and signed request?
A payment was sent more than 14 business days ago and member is disputing the balance due. This is the Support Task type that should be submitted for further research
What is Premium Billing Inquiry Medicare D?
It is ESSENTIAL to ask the caller for _____ _____ and document them in the Support Task
What is Prescriber details?
These are the most common pieces of information that would cause an application to be incomplete.
What are valid MBI, Permanent address, and Reason for SEP or missing SEP event date?
Submit this Support Task Type for member callback/follow-up, when Case Coordinator is closed
What is Senior Inquires?
In accordance with Medicare Part D Compliance, CCRs are REQUIRED to do this when a member requests a voluntary disenrollment.
What is the CCR is required to complete all talk tracks and steps in the Compass MED D SilverScript - Voluntary Disenrollment document?
If a beneficiary would like to apply uncashed refund check to their premium account, this is the code that should be included in the task notes.
What is UCR020?
A call may be transferred to CD&A for these reasons:
What is:
Beneficiary is escalated and insistent on being transferred to the CD&A Team
Case Notes indicate to contact the CD&A Team for more information on the request
Beneficiary calls with approval on file, but medication still rejecting at the pharmacy
Beneficiary wants to withdraw a case that is open or pending
Beneficiary calls with a change in provider/prescriber for an in-progress case
Beneficiary returning outbound call from CD&A Team
Client Representative/Benefit Office wants to speak to CD&A on behalf of the beneficiary
Senior Team’s discretion?
This is when the Opt-Out period expires for a potential enrollee
What is 21 days after the date on the Opt-Out letter?
SRT should create the Grievance only in this instance
What is if Senior takes over the call?
Only this entity can approve or deny a beneficiary’s request for disenrollment
What is CMS?
One-time premium billing payments made at a CVS/pharmacy through INCOMM are visible in Compass within _____ _____ _____.
What is four (4) business days?