Cover Causes & Referrals
Which cover cause would you select if the member states that they have a sore throat and are experiencing difficulty swallowing?
Illness - Cold, flu, sore throat
What are the standard tests that do not require a pre-approval?
EKG, X-Ray, Lab Work (blood & urine tests)
As DC-CSRs, how many consultations can we pre-approve?
We can pre-approve the first 3 consultations. Fourth consultation or more must be forwarded to Case Management.
What type of Communication Note needs to be created when we open an active medical claim?
Benefit Note - Initial Consult
Which departments send GOPs?
Assistance Services and Case Management
MediOrbis handles telemedicine consults for members travelling in which countries?
United States, Mexico and Europe.
Hannah has found a lump in her breast and the doctor wants to order a mammogram to diagnose her. Can we approve a mammogram?
Yes, we can approve mammograms.
Lorraine has serious arthritis in her hands. The doctor has requested that she receive a cortisone injection to help reduce inflammation, relieve pain and improve mobility. Can we approve this?
Yes, we can pre-approve one (1) injection.
If we approve a second consultation, what communication note(s) need to be left on the claim?
Special Note - Claimant Email Correspondence & Benefit Note - F/U Approved
What's the GOP dollar limit for Assistance Services?
$3,500
True or False: Randy slipped and fell on the deck of a cruise ship and bruised his tailbone. This would be considered an MVA claim.
True. Any accident while on a motorized vehicle is considered an MVA.
No, we cannot approve biopsies anywhere other than the skin. Notify Case Management.
Nicholas has been experiencing repeated, intense pain in the upper abdomen. The doctor has recommended a gallbladder removal surgery. Can we approve this surgery?
No, we cannot approve surgery. Notify Case Management.
If we approve a first consultation with a doctor, what needs to go in the Reference field of the contact tab?
TMOV1@TRV
Who do we send disclaimers to?
The claimant or an authorized contact.
Violence - Animal Attack
Nancy's doctor has requested that she get an MRI on her knee after a snowboarding accident. Can we approve this test?
Yes we can! We can only approve knee MRIs when due to skiing or snowboarding accidents.
Patrice has been experiencing muscle soreness and stiffness in her upper back. The doctor has recommended chiropractic care. Can we pre-approve?
Yes we can! As long as there's a benefit in the policy.
What should we do if we cannot obtain all necessary information to fill in the Contacts tab?
If you did not obtain some info, leave the fields empty, and add it to a missing info section of your Communication Note.
True or False: For Hospiten/Grupo Resuce, we can send GOPs up to 48 hours after the client has been discharged.
True. These facilities are an expectation to the rule.
George is 67 years old. He's been experienced a sore & stiff neck for a few days now. He reaches out to GEM looking for a referral. According to George's symptoms, what type of directional care can we offer him?
Clinic or ER only. Telemedicine is not available because George is over 65 years old.
Pete has been experiencing persistent belly pain and diarrhea. His doctor wants to order a colonoscopy. Can we approve this test for him?
No we cannot, as this is an unlisted test. Notify Case Management.
Olivia suffered from a serious burn injury after spilling boiling hot water on herself. After treatment, the doctor requests that she come back to get the bandages changed. Can DC-CSRs approve this?
Yes, we can approve bandage changes.
How do we document authorized contacts?
Communication Note: Special Note - Authorization for Disclosure of Personal Information
Contacts: Add 'auth' to the contact's name
True or False: we can send a GOP for a Sun Life member when VOC has not yet been confirmed.
False. GOPs cannot be sent unless Verification of Coverage is completed for Sun Life members.