Pharmacy
Member wants to know a pharmacy in area. How would you complete this?
Find a pharmacy intent
Member wants a new PCP. Which intent would that be and where can you look to find INN providers?
Search and assign providers and Rally
Member wants to know if Chiropractic visits are covered and if there is a limit for visits? Which intent and category will be used? What does it say?
Review medical benefit and Chiropractic
Member received a bill in the mail from the provider. Which intent would you look to see that claim?
Review medical claim history
Member would like to check her annual maximum. Which intent would you use? And how much is their maximum?
Review medical benefits-Dental/oral services-UHC community plan-EOC-$3500.00
Member is requesting if a Losartan 50 mg is covered?
Formulary Lookup
Member lost her ID card. Which intent will that be in? How long does it take for ID card to arrive to address?
Member materials and 10-13 business days.
Member wants to know what glucose monitors are covered. Which intent and category will be used? What brands are covered?
Review medical benefits and Diabetic services; One touch and Accu-Chek
Member is interested in mom's meals after being discharged from the hospital. Which and intent would you choose and what are the steps after?
Review medical benefits- Value added- I-Cue- contacting USC team if stay was approved or less than 30 days
Member is requesting a dentist in her area. Member is requesting that the list can be emailed to her. Which intent and steps would you follow?
Search and assign provider-Rally-Email/print list at bottom of page
Member wants to sign up for mail order medications. How would you complete this?
Rx Home Delivery
Member expresses that her vision is declining and needs her information in larger print
Member materials
Member wants to know the plan would cover a CPAP machine. Which intent would you use and is it covered by plan? If it is, what is needed?
Review Medical benefits, DME Coverage, Sleep Study and provider's order
Member wants to check OTC balance and wants to know if a bathmat can be purchased. Which intent would you use and what are the following steps after?
Review medical benefits-Value added-Solutran portal-View catalog.
How would you find the member's dental vendor?
UHC community plan site
Toolbox
Member wants to know why her medication was rejected. How would you check to see?
Claim history
Member would like to add email address to her account and changer her phone number. Which intent will that be?
Update member's profile
Member is requesting a home health aide due to more assistance needed in the home. Which intent and category would you use and what does the plan cover?
Review medical benefits-Home health services- Prior to receiving home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort.
Covered services include, but are not limited to:
*Part time or intermittent skilled nursing and home health aide services
*Physical therapy, occupational therapy, and speech therapy
*Medical and social services
Member states that she received a letter that her procedure was denied, and she does not believe that it should be denied. What intent and category will you use?
Complaints, Appeals, Grievances- Appeals
Member needs to get a tooth extracted. Where would you find this information?
EOC
What are the steps for the medication adherence process?
Check claim history
Call pharmacy
Make PCP appt if needed
NAV PLAN
Member requests a need for housing. Which intent would that be and what site is used for finding resources?
SDOH intent and Find Help
Member has a history of addiction to Oxycodone tablets. Member is requesting if treatment programs will be covered? And what facilities are INN. Which intent and steps would you complete this task?
Review medical benefits-substance use disorder- Rally
Member would like to add her sister as a caregiver and her brother as her Authorized rep. Which intent would you use?
Manage auxiliary persons-auth rep and caregiver catergory
Member received a pair of dentures three years ago and dentures broke in half while eating. Member is requesting a new pair. Which intent would you use and where can you find this information? Is the member eligible for a new pair of dentures?
Review medical benefits-dental/oral services-UHC community plan-EOC- Every 5 years- Not eligible.