DUALS
This transfer method shouldbe used when assistingmembers speak with anotherdepartment/vendor/provide
What is a warm transfer?
This is a request for a reviewof a denied healthcareservice or payment
What is an appeal?
This HEART step meanslistening carefully to themember’s concerns
What is “hear?”
How long does it typically take for adeceased member update to beprocessed after being reported toSocial Security?
What is 30-45 days
What is the name of thearticle used to assistMedicare and Duals membersrequesting materials in adifferent format or language
What is Alternate Format Requests Medicare DUALS
This best describes howMedicare and Medicaidcoordinate benefits for dual-eligible members.
What Is Medicare pays first and Medicaid may cover remaining costs like copays and additional services?
This type of complaintconcerns service issuesrather than coveragedecisions
What are grievances?
In this HEART step, youshould clarify the problemand decide the best nextstep
What is “assess?”
A beneficiary enrolled in a MedicareAdvantage plan on January 1stqualifies for what election period?
The Medicare Advantage Open Enrollment Period.
Where is the process for transferring a call internally?
What is Salesforce Phone Gadget Call Management with Genesys
This is the purpose of MolinaCare Connections.
What is to provide home care visits by an NP to members who can’t travel to see a PCP?
A member needs medicationurgently and cannot waitfor a standard review
What is an expedited appeal?
In this stage, agents providetimely solutions and makesure the member feelsconfident and satisfiedbefore ending the call
What is “resolve?”
True or False: A member can cancel enrollment at any time after the OEV letter is sent.
What is False
What KA would you use to decide when to use Hold vs. Mute
What is: Hold is used to reach out to another dept vs Mute is used for researching – Article: Hold vs. Mute Procedures
This is a waiver member.
Who is a member who receives additional services through Medicaid?
Failure to complete this step can delay the A&G department’s ability to resolve a grievance. What is it?
What is failing to obtain all necessary information (or documentation)?
These two steps in the HEART approach help build trust by connecting emotionally with the member and leaving them feeling valued and appreciated
What are “empathize” and “thank?”
Name one reason a member may beinvoluntarily disenrolled
What is Loss of Medicaid, non-payment of premiums, or moving out of the service area
What article would you use to find "the why" we would xfer a caller to CM
Which article outlines agent expectations for handling calls and achieving First Call Resolution (FCR)
This is language thatrespects people withdisabilities, including thosewith mental healthconditions.
What is inclusive language?
This CMS oversight system requiresMedicare Advantage and Part D plans tolog, categorize, and resolve certaincomplaints within strict timeframes, andrepeated issues identified through it candirectly impact Star Ratings and triggercompliance actions.
What is the Complaints Tracking Module (CTM)?
Clarifying uncertaintiesbefore offering a solution isan important part of the“assess” step because ithelps to avoid doing this
What is “giving misinformation or wrong information?”
True or False The guided flow is an optional tool designed to assist agents with the disenrollment and cancellation process.
What is False
Which article outlines agent expectations for handling calls and achieving First Call Resolution (FCR)
What is Call Handling Expectations