Members
What's needed to HIPAA verify a member caller?
Full Name (required)
2 of the following:
DOB
Enrollee ID
Address
Email Account (Only required for IB)
What's needed to HIPAA verify a provider caller?
First name of caller
Provider name
TIN/License #/NPI
Office Address
Member Name
Enrollee ID or DOB
How do you confirm if a call is verified on the IVR?
Check Genesys for the "IVR Verified" field, It will say "YES" or "NO." Also if they're HIPAA verified, MACESS and EBD will auto-populate with their information
What can we use as a last resort if we cannot locate the member?
We may ask for the Social Security Number as a last resort (NOTE: Please ask for the "Social Security Number" do not shorten to "Social" or "SSN" as you will be marked down!). It takes the place of mem id for HIPAA verification.
What can you use to search a Deltacare Provider only in NPF?
Facility ID #
Someone comes in IVR verified. What do you need to continue the call?
Caller name (ALWAYS REQUIRED!)
IF IB ONLY:
Address
Email Account
How long does verbal authorization last for?
One call
What do we do if treating provider cannot be found under provided office location?
We cannot proceed unless they are able to verify a provider under their office location.
If someone comes in IVR verfied, however the caller is not the patient on the IVR, how do you proceed?
Get caller name and reverify them according to guidelines on the HIPAA ORL.
What ALL do you NEED to HIPAA verify someone calling on behalf of an adult on the plan in lieu of PHI Form?
Verbal Authorization (Required)
Caller's Full name and relationship to patient (required)
2 of the following
Enrollee ID,
Enrollee DOB
Enrollee full address
How do you determine if office is inactive in NPF and how do you proceed if it is?
When you look up provider address, on the right side of the screen under "Status" will be either the code "01" or "09". 09 means active, 01 means inactive. If inactive, we cannot proceed, unless they can verify with an active business location.
How can you verify a Group Contact or a Broker?
Caller's first name & company name (required)
BA Agreement (required, located on the HIPAA ORL)
2 of the following:
Group Name
Group Number
Full Group Address
Where can you locate the HIPAA Release Form on file?
There are 3 potential locations; as a pop up in MACESS, under the Remarks Tab in red text, or in the Member Folder.
What do you need to HIPAA verify an Out of Country provider?
Caller's first and last name
Provider's name
Office phone number
Office address
License or TIN
CAN share: Eligibility Status, Benefits, Claim numbers, Sates of Service, All financial details of the claim- Submitted Fee, Accepted Fee, Max Contract Allowance, Amount Applied to Deductible, Paid by another plan, Contract Benefit Levels, Delta Dental Paid Amount, Patient Paid Amount.
CANNOT SHARE: PHI, Member History, Provider detials/information.