Definitions
An expression of dissatisfaction over a service, copay, premium, benefits and more...
What is a Grievance
Can someone explain to me why my claim denied?
What is an Inquiry?
Locating a provider for a member who has been unhappy with their current one.
What is DocFind or FindCare?
The member called in upset that their CPAP machine supplies were not the correct ones.
Who is the Member?
EOC
A routine question about a benefit with no dissatisfaction mentioned....
What is an Inquiry?
I am very upset that my copays went up. I am unhappy with this plan.
What is a Grievance?
To review a Premium Invoice.
What is TransAmerican Direct?
Mrs. Frost called in to let us know she is unhappy with the care her husband received at Herman Memorial Hospital.
DSNP
What is Dual Special Needs Program/Plan?
A provider or supplier that does not contract with a MA organization to provide services covered by the MA plan.
What is a Non-Contract Provider?
The member called in to complain about the rude office staff at their doctor's office.
What is a Quality of Service Grievance?
To review a Member's Reimbursement paperwork.
What is IOP Viewer?
Tom Cat-Broker called in to state that his client Mrs. Minnie Mouse is upset that her plan was changed by a Telesales agent without her knowledge.
What is an AOR/POA?
OEP
What is Open Enrollment Period?
A grievance related to whether the quality of covered services provided by a plan or provider meets professionally recognized standards of health care, including whether appropriate health care services have been provided or have been provided in appropriate settings.
What is a Quality of Care Grievance?
The member calls in to advise their authorization for an MRI was denied. They state they are unhappy about this.
What is an Organization Determination Grievance?
This houses all of the grievances/complaints/appeals.
What is MHK Nitro?
Mr. Eagle called in to complain about his broker. He feels lied to as the broker told him he would get an Extra Benefits Card with $750 on it for switching to this Aetna MAPD plan.
What is the Member?
HHV
What is Healthy Home Visit?
A decision not to review a request for a grievance, initial determination, or appeal because it is considered invalid or does not otherwise meet Medicare Advantage or Part D requirements.
What is a Dismissal?
The member's daughter called in to advise that she is very upset with the care her mother received at a Skilled Nursing Facility. Her mother has diabetes and did not receive the proper food according to her diet which then spiked the her mother's blood sugar and made her sick.
What is a Quality of Care Grievance?
To find an approval or denied CT or MRI authorization.
What is eviCore?
Julie from Aetna Nurse Case Manager called in to MSO with the member on the line. The member stated they are unhappy with Signify Health as the provider never showed up for their HHV (Healthy Home Visit).
What is the Member?
ANOC
What is Annual Notice of Change?