Pharmacy
What are the three types of pharmacies a member may use?
Brick & Mortar
Compounding
Specialty
Where can you find the DME quick reference guide?
KIP
When would an expedited appeal be appropriate?
If a member is being denied services that could result in loss of life or loss of limb
What is a plan year?
The 12 month span in which a member's insurance coverage runs
As of 2019, what was the top selling item on Amazon?
Elastic Exercise Bands
Where can you find out what formulary the member has?
On the Schedule of Benefits
Who submits a prior authorization for DME?
The vendor. They include the product, pricing, and the doctor's script.
How long does a member have to file an appeal?
Within 180 days of the date on the EOB.
What is a schedule of benefits and where can it be found?
A list of the various services covered under a health insurance plan and the associated fees. These can be found by searching the plan code in KIP.
What were the most streamed shows on Netflix in 2018?
The Office
Friends
Grey's Anatomy
What category and activity code do you use to document a pharmacy search?
BNA202
How long is the rental period for CPAP & BiPAP machines?
13 months
How does a member submit a pharmacy exception request?
Drug name, does, dates/durations, and why the formulary medications are not safe or effective
If you get a call about Bariatric Surgery, what should you do?
Gather all the information from the member, route a cutlog to BSB001 for CM or BSB002 for MP, and advise they will receive a call from a benefit expert in 24 to 48 hours.
In 2019, what was the most popular food order in America?
Burrito Bowls
What is the system used to view Pharmacy Prior Authorizations?
PA Hub
What system do you use to view pay policies to see specific indications and limitations for DME?
Policy Manager
What system do you use to view member correspondence related to C&G
MedHok
How long does a member have to complete and return a Transition of Care Request form?
Within 30 days of the effective date of coverage
In 2018, what was the most common pet in the United States?
Freshwater fish
What is an ancillary fee?
A penalty the member receives if they fill a brand when the generic is available. This is the retail price difference between the brand and generic, plus the brand copay.
What are three pieces of DME that are not covered?
Knee Walker
Stair Glide
Blood Pressure Cuffs
Lift Chair
Potty Chairs
InTone Incontinence Device
What is the total time frame a member should be quoted after filing a first level appeal?
40 days total
5-7 to receive the acknowledgement letter
30 days from date of appeal, the decision letter is mailed with outcome
What dental and vision is covered under the medical insurance?
Full boney impacted or partial bony impacted wisdom teeth
Emergency dental services due to trauma
Cataract surgery
Macular Degeneration
Scratches to the eye
What was the number one dog breed in 2019?
Labrador Retriever