Show:
Determine Eligibility
Non-Member
Complaints and Grievances
Providers
Systems
100
If the member is showing eligible in Streamline but not D365 what do you do?

If Streamline shows different eligibility information than Dynamics 365, return to step 2 and proceed based on the eligibility information in Streamline.

100

What is the KA for Non-Member Inquiries?

01106

100

What are the two ways a member can file a grievance?

CareSource MyLife App or by calling in

100

What is the KA for locating a provider?

01375

100

What system do you use to check eligibility through the state?

MITS/PNM

200

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.


200

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.

200

Member calls in to complain about Cleanliness of an Office Site. What is the subject of your case? 

Complaint Against Provider


200

What is a good resource to use for finding DME providers?

Access Resource Guide 

200

What systems can you use to locate providers?

D365 and Find A Doctor

300
What do you need to ensure when checking eligibility for more than one member?

HIPAA; 3 pieces of information

300

What do you advise the member if they got a letter to choose CareSource as their MCP (managed care plan)?

  1. ASSIST: the caller with any questions they have regarding the plan. 
  2. ADVISE: caller to contact the Medicaid Hotline to choose a managed care plan and offer to transfer. 
    • If after 8pm, relay the number and hours of operation and do not transfer.
  3. DOCUMENT the details of the call in the Case Notes.
300

What is the KA for reporting a complaint against transportation?

01125

300

Is a referral required to see a Chiropractor?

No

300

What is the name of the tab in D365 with the wrench?

Case Record

400

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

400

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. 


400

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

400

What system do you use first to locate a provider for a member?

D365

400

What system should you be using to double check eligibility, and updating a PCP only if D365 isn't working?

Streamline

500

When do future members' profiles generally get posted in D365?

 within five days of the effective date

500

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.

500

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

500

How many providers should you give the member at a minimum?

2

500

What is the name of the system used to take calls? This also tracks breaks, lunches, and not ready statuses. 

Bucher and Suter