MIOD
With a transportation MIOD what is the first thing you should offer the member?
(exhausted benefits)
Community Resources
Medicaid Transportation
MUST be documented in your CAG intent
If member complains about long hold music while waiting to speak to someone how would we categorize this complaint.
Verbal grievance: part C, customer service
When handling Quality of Care Issues, make sure to document the following:
what exactly is the issue causing it to be a QOC
what is the indication that the member was unable to receive care or their care was affected
Expedited CD Turnaround times
PA and B vs D:
Handled within 24 hours from the time of the call.
QL, ST, Formulary Exception, Part D Excluded and Tier Exception: Handled within 24 hours after the plan receives a supporting statement from the physician or prescriber. The prescriber has up to 14 days to provide the information for the review.
Expedited
Handled within 72 hours after the plan receives the request in the mail.
Member calls in stated the transportation driver was rude and yelled at her: how do we categorize this grievance
transfer to SafeRide
All MIODS are a two part process. What are they?
Cag intent and INFOPATH
If a member complains that they experienced a long wait at their provider’s office to obtain a prescription (but the member ultimately obtained the prescription), should this be classified as Part C or Part D?
Part C.
Since the member was able to obtain the drug, the complaint is not about access to their Part D drugs or benefits.
The member goes to the provider and waited over 30 minutes to be seen, but was seen by the provider is this a QOC.
yes wait time over 30 min is a QOC
What do we tell a member requesting a coverage determination on a Friday, if requesting an expedited decision
Advise the member requests made on Fridays, weekends, or holidays may be denied due to a delayed response from your doctor's office as they may be closed.
member calls in stated he really is frustrated with Avery the IVR system taking too long to get him to his navigator. How is this grievance categorized
Customer Service, technology
What should your first step when filing a MIOD be?
confirm members plan benefits
Who can file a VG?
member, POA and AOR,
AR (You need explicit member permission if AR is the one calling in)
member called stated transportation never showed up to pick her up and she had to reschedule her appointment for 2 months from today is this QOC
yes
once you submit the information in PAS what do you enter in Maestro.
Capture the confirmation number that was provided after submission of the form
member calls in upset because their credits for OTC wont roll over
plan benefit , OTC healthy food and utilities
How long does an Organization Determination take to process?
Standard Request: 14 Days
Expedited Request 72 hours
Coverage Determinations:
Standard Request: 72 Hours
Expedited Request: 24 Hours
What statements should trigger a VG path?
Who can file a QOC?
Anyone 3rd party can file
member calls and wanted to know why they were denied for Botox and wants it to be covered for their migraines is this a CD
yes
member is upset because their ID card has the wrong PCP listed.
fulfillment, member materials not received incorrect
After you click submit the INFO path form what happens next?
Pop up states:
Two of the most important pieces of documentation are:
According to Access to standard of care standards what is the criteria for New patient appointments?
14 days
Do we file CDs for Medicare excluded drugs?
yes
member is upset because their utility bill is not paid on time. how would you categorize this
OTC, Healthy Foods and Utilities