Flags
Coverage Determination
QOC
MIOD/OD
Verbal Grievances
Call Categorization
SOP
100
Bangladesh
100
Member calling for a CD for the current plan year w/o expression of urgency.
What is a standard CD?
100
Has the potential to result in physical or mental harm, such as a worsened medical condition
Antarctic Blue Whale
DOUBLE JEOPARDY: DOUBLE POINTS
100
Standard OD plan must make a decision in this time frame.
What is 14 days?
100
Who, What, Where, When, Why, How
What are the documentation requirements?
100
Rude behavior,
Misinformation
Difficulty understanding
Advocate Interaction (Gyms, Nurse Line, Advocate Representative)
100
What Job Aid tells you who can submit an Organization
Determination
DOUBLE JEOPARDY: DOUBLE POINTS
SUBMITTING A COVERAGE DETERMINATION
200
Belgium
200
Prior Auth, Step Therapy, Quantity Limit
What are the reasons for filing a CD?
DOUBLE JEOPARDY: DOUBLE POINTS
200
Misdiagnosis
Delay in referral, treatment or diagnosis
Complications and/or factors contributing to death.
Australia
200
This OD must be completed no later than 30 days after the request is made.
What is a Post Service OD?
DOUBLE JEOPARDY: DOUBLE POINTS
200
Identify
Resolve
Document
Categorize
What are the tips used to successfully handle a grievance?
200
Member upset for wait time to reach a rep/advocate
Member upset about excessive transfers
Member upset about the time spent on the phone with the rep/advocate
Complaint About (Transportation Vendor) Call Time/Hold Time/Transfers
200
Where would you locate the information that must be documented for all QOC issues?
SYSTEM DOCUMENTATION-APPEALS, GRIEVANCES, CDs & Ods
300
Australia
300
Application used to check for existing CDs and create new ones.
What is PAS?
300
Name of the QIO Org
QIO Address
QIO Website
QIO Phone/fax #s
?
Sheep
300
What 2 instances do we not use the MIOD form but warm transfer?
300
Complaints about medical services, doctors, facilities, etc.
What services are coded under medical Part C?
300
Broker gave incorrect information when enrolling them into the plan
Broker enrolled the member into the plan without their knowledge or consent
Broker/Agent rude
Sales Agent/Broker Fraud, Misrepresentation or Behavior
300
What Job Aid would assist an advocate if a member is expressing dissatisfaction with a specific Pharmacy?
GRIEVANCE HANDLING-PART C vs PART D & FAQ
400
Spain
400
natural disaster, dosage change,
What are the reasons for an override?
400
Name of prov/fac/hosp/pharm
Person-1st & last name
Address of prov/fac/hosp/pharm
House Calls & Transportation- where member needs to go and contact # of the party he needs to see
Contact- phone number
Etc.………….
AB negative
400
I-CUE
Where to look for MIOD, OD, AND PA request?
400
“I received a bill”
“Please stop with all the calls”
“Transportation was late picking me up, but I made it to my appointment”
“The receptionist in the doctor’s office was rude”
What are examples of why a Standard Grievance would be filed?
400
Outbound campaign/promotional calls
Outbound campaign/promotional mailings (brochures, advertising, commercials, emails)
Excessive Calls and Mail from Plan or Plan Vendors
400
What Job Aid tells you how long after receiving a Notice of Denial does a member have to submit an appeal?
COVERAGE DETERMINATION STATUS > PRIOR AUTHORIZATION DENIAL
500
Haiti
500
Jackie Chan
500
This essential gas is important so that we can breath
Oxygen
500
Non-covered benefit
Benefit Limit/Allowance
Network Gap Exception
CoC/ToC
What are examples a MIOD would be filed?
500
When do girrafe have 8 feet
When there is 2 of them
500
Does not like or never requested automatic refills
Billed credit card without authorization
Requires certain approvals for prescription services
Complaint About Optum Rx Operations/Polices
DOUBLE JEOPARDY: DOUBLE POINTS
500
This Job Aid tells you what time zone should be used when filing a MIOD?
DOUBLE JEOPARDY: DOUBLE POINTS SUBMITTING MIOD REQUEST
600
Panama
600
James Brown
600
When you make light change direction by passing it through a lens.
What is refraction.
DOUBLE JEOPARDY: DOUBLE POINTS
600
A request to pay for or authorize a service to which the member believes he/she is entitled.
What is the PA process/what is an OD?
600
What can you hear but not touch or see and yet control?
your voice
600
Member received a call from someone claiming to be from UHC.
Suspicious Phone Calls
600
What Job Aid has 2 options for documenting Provider Info on Transportation QOC issues?
GRIEVANCE HANDLING
700
Double Jeopardy: Double Points
New Zealand
700
DOUBLE JEOPARDY: DOUBLE POINTS
Fidel Castro
700
The amount of elements on the periodic table.
118
700
Plan must make a decision in 72 hours.
What is an expedited OD?
DOUBLE JEOPARDY: DOUBLE POINTS
700
You are my brother, but I am not your brother. Who am I?
I am your sister.
DOUBLE JEOPARDY: DOUBLE POINTS
700
PCP refused to refer a specialist
Provider will not submit referral
Referral not received by specialist
Missing documentation needed
Unable to Receive Referral
700
What Job Aid would assist an advocate in attaching a note to a request in the PAS?
FILLING OUT A COVERAGE DETERMINATION REQUEST FORM – ATTACH A NOTE
800
India
800
Tony Blair
800
Who was the first man to walk on the moon?
Neil Armstrong
800
A specific dental benefit or service
( e.g. extraction, crown, cleaning).
What can a member submit an OD request for regarding Dental?
800
Say my name I dissappear.
Silence
800
Member unable to login to account
Website down
Unable to download/print forms
Difficult to navigate
Plan Web/Internet/Email
800
The member is going to see Dr. Jones and transportation does not pick him/her up. The member did complete their visit. Which Job Aid identifies what type of grievance this is?
GRIEVANCE HANDLING – QOC IDENTIFICATION
900
Russia
900
Maureen O'Hara
900
The planet that completes its rotation the fastest in just 10 hours.
What is Jupiter.
900
This is a decision about Part C payment or benefits made prior to the effective date of a member's plan.
What is a MIOD - Advanced Requests (AEP)?
900
Poor people have it. Rich people need it. If you eat it you die. what is it?
Nothing
900
Note: Select this option if the member’s grievance has been identified as a QOC grievance.
Inadequate Care (QOC)
DOUBLE JEOPARDY: DOUBLE POINTS
900
Which Job Aid would you go to and see if a member has an approved Coverage Determination?
SUBMITTING A COVERAGE DETERMINATION REQUEST
1000
Double Jeopardy: Double Points
Afghanistan
1000
Stompin' Tom Connors
1000
Fastest land animal?
Cheetah
1000
Info Path Form.
What form is used for a MIOD Change/Cancellation?
1000
When is it a bad time to see a black cat
When you are a mouse
DOUBLE JEOPARDY: DOUBLE POINTS
1000
Received someone else’s member material.
Received Another Member’s Materials (PHI or HIPPA Breach)
1000
What Job Aid will assist you with the reason/sub reason the member is expressing dissatisfaction for not receiving a formulary after speaking with advocate 4 times?
GRIEVANCE CATEGORIZATION