M&R DSNP
DSNP members have ____ & ____.
Medicare and Medicaid
Tool to be used in viewing member eligibility and in checking member's Medicaid MCO
DMEVS
The document that describes any changes to the Member benefits, coverage, costs, premiums and/or service area that will be effective in the new plan contract year.
Annual Notice of Change (ANOC)
A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.
HIPAA
A health-related activity wherein a nurse practitioner will go to a member's house
Housecalls
An annual process by which members report their income to the state to redetermine their Medicaid eligibility.
Medicaid Redetermination
Houses all SOPs and jobaids
Knowledge Central
A set time each fall when Medicare Advantage (MA) AND Medicare prescription drug coverage Members can change their health or drug plans or switch to Original Medicare.
Annual Election Period (AEP)
Examples of Caller Types
Member
Authorized Representative
POA/ Guardian / Conservator
Trustee
Attorney
Broker
Employer Group
Foster Parent (C&S Only)
Insurance Company
Internal Caller
Media Representative
Parent / Guardian of a Minor
Provider
SHIP Counselor
Third Party- Others
Federal / State Regulator (SPAP, CMS, State Medicaid Agency
Which intent may you use to send non-PHI forms and information to members with MA/MAPD and PDP individual plans?
Send Informative Email
A Federal insurance program that caters individuals over 65years old and/or having long term disabilities
Medicare
Used in submitting D-SNP members' plan cancellation.
EWD MRBE Portal
A department within the Plan responsible for answering questions about membership, benefits, grievances, and appeals.
Customer Service
True or False: We are allowed to disclose general information about the member's account if the caller is not the member
True
What is the name of the tool that allows us to locate providers?
werally
Medicare Open Enrollment Period
October 15-December 7
A tool used to locate exisiting housecall appointments or missed housecalls.
Housecall/Member Status (optum.com)
A list of prescription drugs covered by the plan. The list includes both brand name and generic drugs.
Formulary
True or False: A new email address cannot be added without the member’s verbal consent.
True (Ref KM1007997)
Intent used if member is requesting a comprehensive formulary list
Member materials
A Federal agency who is responsible for the oversight of Medicare and Medicaid
CMS- Center for Medicare and Medicaid Services
A tool used to check Medical Prior Authorization
ICUE
Refer to Non-Contracted Provider
OON (Out of Network)
True or False: If the caller is a broker, member does not need to be present to provide permission; the broker only needs to verbally attest that they have received permission from the member.
True (Ref KM1004106)
Under what intent can we pull up DME List?
Review Medical Benefits