Claims (DUMDUMDUM)
What systems will we see Medicaid claims?
Maestro
CSP Facets
Do we have to document in Maestro that we went to Find Help (Healthier Lives Website ) ? If so, where do we document that?
Yes - and it is under the Social Determinants of health intent (SDOH). You would launch that intent and document what organization you referred the member to in the Find Help Website AKA Healthier Lives .
What is a Medical Prior Authorization called?
Organization Determination (OD)
What are the 3 Medicaid Eligibility Levels?
Full Medicaid-No Copay Full Medicaid Benefits, Member responsible for Part D copay, Provider must bill Medicaid, Provider cannot balance bill member
QMB only- No Copay, NO MEDICAID BENEFITS, Member responsible for Part D copays, Provider must bill Medicaid, Provider cannot balance bill member
Partial Medicaid- Has Copay, Has NO MEDICAID BENEFITS, Member Responsible for Part D Copay , Member will get Bills from provider
If a member needs a coverage determination what are the 2 systems we are gonna use?
Maestro and PAS
What intent in Maestro will we use to view bills the members think they have
Review Medical Claim History
When Referring a member to a program through Find Help, how can we share the information with the member and what platforms can we use?
Tell the member the information
Or hit share and we can....
Text or email....we cannot use Facebook
What is a Part D or Medication Prior Authorization called?
Coverage Determination (CD)
A member has Medicare and Medicaid with the same insurance company. What is this called?
Being Aligned
What is the difference between part B and part D drugs?
Setting that they are administered.
B drugs are given to you by a professional and in medical settings
D dugs are self administered and usually taken at home
If a doctor bills a member for the amount that was disallowed, or bills them for more then the contracted amount what is this called?
Balanced Billing
What system will we use when we want to look up resources that might not be in the plan, but can help member with food, clothing, housing, and transportation?
FindHelp AKA Healthier Lives Website
What are they systems and intents used for an Organization Determination
1. Maestro
2. Complaint Appeals and Grievances Intent
3. MIOD SharePoint (Member Initiated Organization Determination)
Where can I find what language them member speaks?
Member Summary or Member tab
If a member has a rejection at the Pharmacy what 2 systems can I look in to see that rejection?
Maestro and RX claims
What system can we look in if a member says they received a bill from UHC to see what they are talking about?
DOC 360 - most the time they say a bill, but it is the EOB. (Although it says in big Letters NOT A BILL at the top of the page.)
What are Key Phrases that indicate a member may have unmet needs?
I don't have enough food
I can't pay for utilities
Need help finding housing
What are the systems and the intent you use to do a Coverage Determination
1. Maestro
2.Complaints Appeals and Grievance
3. PAS (Prior Authorization System)
How will I recognize a Gap in Care? How do I close the gap in care?
1. Look at the members record in Maestro see if there is an NBA
2. Follow the scripting and go through all the NBA on the account
If a member is in plan H1045-039 and is LIS level 2 what is their copay at the pharmacy?
2022 is no buy down then Generic is $1.35 and Brand $4.00
When looking at the claims in facets, how can we tell if Medicaid has paid ?
Open Wrap account or the FLMW plan and check to see if line paid has an amount in it if it does Medicaid has paid the claim .
Before we send a Referral or give any of the member's information out in FindHelp , what is the important thing you must do ?
Get consent from member ... if you do not get consent then you cannot log referral - go back to Maestro and say customer refused, but still give the member the contact info for the program
Member calls in saying that she needs a Prior Authorization and she doesn't know if the doctor had started the process what are we going to ask and where are we going to check?
Ask your probing questions : what the Prior Authorization is for either Medical or Medication.
Medical- look in maestro under summery tab Recent Medical Claims and press the Prior Auth. button to see if it has been approved . Also check ICUE to see notes if it was denied to see why.
Medication Look in Maestro under summery tab and look in Prescription Plan and click the Prior Auth. Button to see if there is information there also check PAS to see notes of why it was denied or what they are waiting on.
What happens if Bubby J calls in for his Aunt and he is not listed on file?
1. Advise the caller that they are not on the account as an Authorized Rep. We can ask if the member is available to give consent and and add on account per members request.
If not available then we need to HIPAA Verify the caller and Share Basic Plan Information
IE:I can provide you with Basic Plan Information. Information can also be found on our plan website.
You should not volunteer information.
You Should not Discuss Member Specific copays or price estimates.
Do not provide Medicare Beneficiary ID (MBI) to anyone but the member, unless otherwise indicated in the individual caller type job aid.
What are we going to do to get a member an override?
1. Look at pharmacy claims to see why the medication is rejected
2. Determine the type of override that is needed
3. Contact Optum RX to see if override is available
4. Warm transfer to Optum RX
Explain to me how to open the wrap plan in facets
Open members account, open new application, search by last name and DOB, and find Florida wrap plan (FLMW)
Member calls in saying she lost her purse and she needs to get all her cards and just doesn't know how she's gonna make it though the month. What can we do for her?
Use probing questions and ask what help she may need...
Food, rent, lights, transportation, gas money, medications a lot can be in someone's purse.
Ask probing questions about what cards : UHC ID, Medicaid ID, Healthy Food card, OTC cards. Just a few cards that might need to be replaced.
For Member ID: send non marketing Material
For Medicaid ID: transfer to Medicaid
For Healthy Food or OTC benefits: transfer to appropriate department
For everything else lets Start the SDOH intent and ask questions then go to FindHelp
Where will we check to see if a member needs a prior authorization?
1. Medical Review medical benefits (if have the procedure code can check prior authorization list above benefits)
2. Medication look in Formulary
Member calling in to see if an MRI is covered and what their copay is... Tell me the steps to give them the correct information.
1. Find member in maestro (fully HIPAA Verify NEVER FORGET HIPAA)
2. Look at Medicaid History to see what level of Medicaid member is (if full or QMB only NO COPAY)
3. Review Medical Benefit to give all stipulations and limitations
What Diabetic supplies are part b and what diabetic supplies are part D
*use job aid*
there are 8 part B and 8 part D
Good LUCK
B:
Blood sugar (glucose) monitors
Continuous Glucose Monitors (CGMs) and their components under the Medicare Part B Diabetic Monitoring Supplies benefit, when supplied by a DME provider.
Lancet devices and lancets
Glucose control solutions for checking the accuracy of testing equipment and test strips
Therapeutic shoes
Non-disposable Insulin pump (external
Insulin (used with insulin pump)
PART D
Disposable Insulin pump (Examples: Omnipod and V-Go)
Alcohol swabs
Gauze
Injection devices (like jet injectors
insulin pens
insulin (without the use of an insulin pump)
Insulin Syringes
Insulin Needles