Accumulations
This term describes a plan where accumulations include both pharmacy and medical benefits.
What are integrated accumulations?
Under Departmental Policies, what system provides coverage for when a CSA takes PTO?
Buddy Support
You start your shift and need to work all open items where do you look?
A. Chatter Feed
B. Case Queue
C. App Launcher
Answer: B. Case Queue
True or False?
Specialty medications are generally not part of the standard High Dollar Claim Review (HDCR) gross cost rejections?
True
I once paid claims and covered meds,
My members had dates with “active” heads.
Now every row ends in a date long past,
No current coverage, no claims to cast.
In Data Net’s halls I still remain,
But only as history, not future gain.
Who am I?
What is a termed client?
This type of accumulation requires two or more members to meet a specified amount together before coverage benefits change.
What is embedded?
True or False:Any clinical nonformulary exception authorization will be handled by the clients appointed PA reviewer.
True
Claims are flowing! The fix is done!
The dragon’s slain, the prize is won!
With proof in hand and systems right,
We close the quest—victory in sight!
What is a closed case?
What are the two drugs that are Formulary Exclusions for all three PBM’s?
What is Humira and Stelara?
Guarded by a fearsome sea monster and hidden beyond the charts of lesser sailors, this is the spot in Data Net you must brave to uncover the elusive PA reviewer.
GIS or Coverage
This plan design strategy prevents manufacturer assistance dollars from accumulating toward a member's deductible and maximum out-of-pocket (MOOP).
What is True-Accumulation?
What is a common reason teams struggle to find information in Confluence?
A. The information does not exist B. Pages are always outdated C. Search strategy and page structure vary D. Confluence is only for leadership
C. Search strategy and page structure vary
A client request comes in that feels unclear. What is the BEST first step?
A. Start researching immediately to save time B. Respond asking the client to clarify everything
C. Clarify the intended outcome before taking action D. Escalate to a Team Lead
Answer: B. Respond asking the client to clarify everything
This PBM has no overrides on their Block List.
What Is Optum?
I guard the truth of coverage, hidden in Data Net’s maze. Seek me before you celebrate the claim you plan to raise. Click the right path, let dates and details show— What action reveals if the member’s benefits are a “go”?
What is the PBC?
This type of deductible or Maximum Out-of-Pocket (MOOP) requires the entire family amount to be met before benefits or copays apply and can be satisfied by one member or a combination of family members.
What is non-embedded?
What PBM has the reject code R E5?
What does the reject code stand for?
Caremark/ Anything related to the Broader Vaccination Network.
Hidden at the top of the message lies the key to the quest—these vital details must be etched into the subject line to unlock the path forward.
Which Coupon Maximizer Cannot be implemented on Qualified High-Deductible Health Plan (QHDHP).
What is Variable Copay?
When a caller’s ID card clues don’t match the pharmacy’s map, this is how you navigate Data Net to uncover the true BIN and PCN and ensure the claim reaches the right treasure chest.
General Temp Card
Two systems apart, yet working as one,
Tracking your costs until limits are done.
They pass back and forth what you’ve paid to date,
Through files that recur so nothing’s outdated.
When pharmacy and medical must both stay in sync,
What is this process that forms the link?
What is Integration.
A conversation already done,
But questions linger—what went on?
I’m sent to rewind the spoken past,
So every word can be heard at last.
Not the call, but the ask to see,
What’s the name of a request like me?
Member Services Call Pull Request
Hidden within the case itself—safely logged like a message in a captain’s journal—this is the way you send and record clues so all future explorers can follow the trail.
When a medication’s blocked and not on the list,
And approval is needed—it can’t be dismissed.
You don’t go it alone or guess who to call,
There’s a strategic team that handles it all.
They work behind scenes where decisions are made,
To open the door for exceptions conveyed.
Who are they?
Who is PBM Strategic Relations?
When the trail reveals a coverage start date still on the horizon and no active mark for today, this discovery in Data Net tells you the member’s benefits have not yet begun.
Future active date