Benefits/Verification
Which benefit would you quote for members requesting coverage for an annual bone density scan?
Bone Mass Measurement;
What does BIN stands for?
Bank Identification Number
What tool we need to use whenever PFP is not working
PAAG
How long does it take an expedited authorization?
72 hours
A Kentucky doctor is listed in Find a Doctor's (Physician Finder) with a six-digit PCP number as 123456 - how do you input this PCP number?
V123456
Under which part of Medicare is a glucose monitor covered?
Part B
How long is a member responsible for a Late Enrollment penalty?
For as long as the member has a prescription drug plan, or until they qualify for low income subsidy
Can nurse practioners be placed as primary care doctors?
Yes
What tool do you use to check if a referral is needed?
Referral Guidance Tool
On CI, what page is the one you use to review the status of a Creditable Coverage?
PCCV
Mention 2 services covered by Home HealthCare.
Skill Nursing, Physical Therapy, Occupational Therapy, Speach Therapy, Wound care,
What type of overrides are we allowed to performed?
Mail order delay and COB
What C/I we need to use whenever a member perceived lapses in quality of care, agent of the plan or a provider
Complaints and Compliments/ QAA
A medical authorization pending status for a non-urgent/non expedited appeal should not exceed this timeframe.
14 days from date of request
What Mentor document would you use if a caller is asking to speak with someone in the United States?
Onshore Transfer Request Calls
Under which category would you quote cataract surgery?
Surgery Services- Copay per eye
What does the status code 71 stand for?
Finalized Denied Claim
What is the name of the filter on PFP where you can see the results from near to far.
"Sort By/ Distance"
What is the status of a duplicated medical authorization in CRM?
Voided
What is the name of the mentor document where all mentor updates are posted?
Medicare Hot Topics
Miss Victoria has not met her deductible, which limit is $700, and has a $25 copayment (for Office Visits). She has paid $175 out-of-pocket already this year. Dr. Goss is billing $200 for an extensive office visit. What is the member`s responsibility?
$25
Provide a brief explanation of the Coverage Gap
70% manufacture, 25%-member responsibility and both count towards the accumulation.
True or False. All Medicare HMO plans required an assigned PCP?
True
How do you check the vendor who handles a medical authorization?
Humana Customer Care Preauthorization and Notification List (PAL)
What C/I to use whenever filing a grievance?
C/I needed to use will be depending on the call type handling.