Determine Eligibility
If Streamline shows different eligibility information than Dynamics 365, return to step 2 and proceed based on the eligibility information in Streamline.
What is the KA for Non-Member Inquiries?
01106
What are the two ways a member can file a grievance?
CareSource MyLife App or by calling in
Member was told at her vision apt that she no longer has coverage… when checking the system you see there is coverage. What KA and steps are you going to take
01550
What system do you use to check eligibility through the state?
MITS/PNM
Should you give the member or non-member their MMIS number if they do not have a profile in D365?
Do not relay the member's MMIS # if there is no profile in Dynamics.
How do you create a case for a non-member that has never had CareSource?
Press New Case from the home screen and add a contact in the "on behalf of" field.
Member calls in to complain about Cleanliness of an Office Site. What is the subject of your case?
Complaint Against Provider
Member was told she needs to get a document showing her coverage. What KA and steps will you take.
ka-01215, advised Caresource is unable to provide Certificates of credible coverage & refer them to jfs.
in 365 what do you resolve first.
child case
parent case.
HIPAA; 3 pieces of information
What do you advise the member if they got a letter to choose CareSource as their MCP (managed care plan)?
What is the KA for reporting a complaint against transportation?
01125
Member wants to order ID card for her and her children. what KA will you use, and what are the two main things you must ask.
KA-01114 , if the address is correct, and pcp
What is the name of the tab in D365 with the wrench?
Case Record
Who does the case get routed to if the member is showing active in MITS/PNM but not in Streamline or D365? How long does it take for them to update it?
ENROLLMENT; they will be notified of a resolution within 48 business hours
What do you do if the non-member who is Medicaid eligible wants to switch to CareSource from another MCP?
Provide the phone number to the Medicaid Hotline and offer to transfer the caller to enroll.
When filing a complaint against transportation what do you need to do after filing the complaint in D365?
Call Provide A Ride for the member to file a formal complaint with them
Rachelle Schmidt calls to report a complaint. The member was seen by Dr. Waldman, Carlisa E. for an UTI. She states that she told the staff multiple times she has a severe allergy to latex. Dr. Waldman ignored this warning & used latex gloves for her exam resulting in the member having a severe rash that lasted 3 days.
What type of complaint is this & what KA would you use?
Quality of care- KA-01650
when transferring a call in 365 you resolve the case.
no- save & close because you did not resolve the members issue, the next CCS will resolve.
When do future members' profiles generally get posted in D365?
within five days of the effective date
What do you do if the non-member is not Medicaid eligible and wants to join CareSource?
They can contact their local County Department of Job and Family Services for further assistance or they can apply for benefits on the Medicaid website at medicaid.ohio.gov.
What is the timeframe for a grievance to be resolved if its not due to not able to obtain medical care, or receiving a bill?
30 calendar days
you get a call, the member shows up not validated. what are the steps you will take to pull that account up.
What is the name of the system used to take calls? This also tracks breaks, lunches, and not ready statuses.
Bucher and Suter