PCP & Providers
This may show as approved in OMNI comments but not display immediately.
What is a PCP change that may take time to display?
What is: when no preferred PCP is on file and a new request helps populate display?
What is Embark (often shows it first for those states)?
This system is state-specific.
What is Softheon?
Usually submits prior authorizations.
Who is the provider?
Something agents must never guarantee.
What is coverage or timelines?
This is NOT the same thing as a PCP.
What is a medical group?
True or False: Agents can manually force a payment.
What is FALSE?
Always check THIS first before escalating.
What is OMNI?
What to submit if a PA is claimed as fraud.
What is a grievance?
The best replacement for: ‘My supervisor will call you today.’
What is: ‘I can schedule a callback based on availability’?
These must be verified before assigning a PCP.
What are PAR status and age limits (HAT code rules)?
After this grace period, payments typically cannot be accepted.
What is the three-month grace period?
This request is needed if you’re locked out.
What is a Request Central ticket?
True or False: Agents can cancel approved PAs.
What is FALSE?
This protects the agent AND the member.
What is clear documentation?
Same office, same address — but still invalid because of this.
What is an age restriction / HAT code mismatch?
This makes billing an Access to Care issue.
What is: member can’t access meds or urgent care because of billing status?
Where payment return reasons may appear.
What is the payment portal / Softheon / Embark payment history view?
Required when seeing specialists outside a PCP group.
What is a referral?
Why over-promising causes escalations.
What is unmet expectations (trust gap) leading to escalations?
DAILY DOUBLE: When does resubmitting a PCP request help?
What is: when no preferred PCP is on file and a new request helps populate display?
DAILY DOUBLE: What should you NEVER promise about payments?
What is: same-day posting, immediate activation, or coverage guarantees?
DAILY DOUBLE: This system is NOT the same as OMNI.
What is Softheon (separate system)?
DAILY DOUBLE: What’s the correct first step for PA ‘fraud’ concerns?
What is: submit a grievance and document the member concern?
FINAL ROUND PRACTICE: The #1 phrase agents should avoid.
What is: ‘I promise’?