Cover Causes and Referrals
Which cover cause should be selected when an individual reports severe sunburn resulting from prolonged sun exposure?”
Illness/Sunburn
Which tests are classified as standard and do not require pre‑approval?
EKG, X-ray, Lab Work (blood & urine)
How many consultations can DC CSRs approve?
V1, V2 & V3.
What does TMO stand for?
Treating Medical Officer
Which two departments send GOPs?
Assistance Services and Case Management
What referral options should be considered when an individual reports receiving a spider bite?”
Telemedicine or Clinic. Hospital in severe situations.
Bob requires a knee MRI after tearing ligaments and straining muscles from a fall on ice. Can his knee MRI be approved by DC-CSRs?
No. We required consultation notes before we can pre-approve. Must notify Case Management.
How many tetanus shots can a DC CSR approve?
Up to 3
What would go in the reference field when creating a contact for a facility?
TMOV#@TRAVEL
What is the Sun Life exception for GOPs?
GOPs cannot be sent unless Verification of Coverage is completed for Sun Life members.
True or False: if someone slips and falls on the deck of a cruise ship, this is considered an MVA.
True. Any accident that occurs on a motor vehicle is considered an MVA.
Can DC-CSRs approve mammograms?
Yes, they can!
Can DC CSRs approve a physiotherapy appointment?
Yes, as long as it's a new medical emergency and there are appropriate benefits in the policy.
What communication note must be creating when opening active med claims?
Benefit Note - Initial Consult
True or False: if I engage GEM Latam, they will send the Disclaimer for me.
False. GEM is to send all Disclaimers, even when other TPAs are engaged.
What is the appropriate cover cause to select when an individual reports being attacked by a dog and sustaining severe cuts and scratches?
Violence/Animal Attack
Can DC-CSRs approve liver ultrasounds?
Yes, they can!
Can DC CSRs approve dental visits?
Yes, as long as there are applicable benefits in the policy.
If you approve a test during a subsequent interaction, what note(s) must be left?
Special Note - Claimant Email Correspondence and Benefit Note - Test Approved
Which facilities are eligible to receive GOPs up to 48 hours after a patient’s discharge?
Hospiten/Grupo Rescue Group
For which regions does Mediorbis provide telemedicine consultations?”
United States, Mexico and Europe.
Margot requires a colonoscopy due to IBS and painful bowel movements. Can her colonoscopy be approved?
No, this is an unlisted test.
If the claimant is asking for a consult that is 14 days or more from the time of interaction, can we approve it?
No, notify Case Management.
What goes in the Attention field of the Contacts tab for facilities?
Doctor's name (if you have it) or the facility name
If we receive a GOP request for exactly $3,500, which team is responsible for sending it?
Case Management