WEEK 1
This is the election period that will start from October 15 to December 7.
Annual Election Period / Annual Enrollment Period
Where can we process a reprint of the member's Explanation of Benefits?
Doc360
Gym Benefit
Coverage determination type wherein the member can request for a plan to cover a medication that is not included in the formulary
Formulary Exception
What is the turnaround time for the billing statements?
7-10 business days
This period provides Medicare Eligible Individual an opportunity to enroll in Medicare and is a seventh-month period surrounding their birthday.
Initial Election Period
If the providers information will not reflect on Werally, where can we check the information of the provider?
Nice and COSMOS
What are the plans that has OTC and Food Credits?
Complete Care Plans
This is a program that will help the members spread out their out-of-pocket costs and manage their budget
Medicare Prescription Payment Plan
If the member is having a hard time paying for their prescriptions, give at least one help we can provide to the member
State Pharmaceutical Assistance Program
Low Income Subsidy Program
Find Help Resources
Drug Manufacturer Coupons
This election period happens from January 1 to March 31.
Open Enrollment Period
This is a program where a licensed health care practitioner (Nurse Practitioner, Physician Assistant or Medical Doctor) will visit eligible members in their own homes
Housecalls
If the member expresses dissatisfaction with the IVR, the services they have received from the doctor or the accent of the agent, what intent are we going to use?
Complains, Appeals and Grievances.
What happens during crossover claim?
Member's claim will transition from 1 coverage stage to another. They will have to stages in one claim.
What is the intent to use if the member is trying to check the covered drugs under his insurance?
Formulary Lookup
Part A
Inpatient / Hospital Coverage
What intent are we going to use if we are going to send replacement ID cards, pharmacy directory, provider directory, and etc?
Member Materials
What are the transportation providers affiliated with the United Healthcare?
Saferide / Modivcare
If the member's claim is capitated, what is the sign that we can see on the claim?
* or Asterisk
What is the process for the Override?
1. Contact the helpdesk for eligibility
2. Ask for the rejected claim from the pharmacy
3. Activate the override from the Help desk
4. Reprocess the claim
5. Advice the member that they can pick up the medication in the pharmacy.
Part C
Medicare Advantage
What are the things to inform the member if they requested for an ID card? (say this in a spiel)
*Turnaround time (14 business days)
What is the process for Mom's Meal?
1. Check the coverage if the member has Meal Benefit.
2. Verify if the inpatient cases/history on ICUE
3. Contact UCS to verify if the member is eligible
4. If yes, transfer to UCS for them to transfer to Mom's Meals Dept.
What are the 3 types of pharmacy in United Healthcare?
1. Preferred Retail Pharmacy
2. Standard Retail Pharmacy
3. Mail Order Pharmacy
What is Catastrophic Stage?
This is the stage wherein the member already met the certain amount of the OOP for the year 2025. They will no longer pay any amount until the end of the year.