Authentication & HIPAA
What does the green and red color mean in the interaction log when we received a call?
Authenticated (in green) for authenticated calls
Unauthenticated (in red) for unauthenticated calls
A member wants to have a copy of his formulary drugs because he is not sure if all of his drugs are covered. What tools we use to send him a copy? Show me.
Provider Directory
What C/I we use when a member is calling to make a ride appointment to go to her doctor's office?
Transportation/Scheduling
What is the denial error that appears on RX Nova when a member is trying to fill a specialty medication on a retail pharmacy?
299: Specialty Pharmacy Required
What are the 2 most common alerts that appears on the member's account?
Contact Handling Alerts (IPA)
Guidance Alerts (RX)
If we are speaking with the member directly, what button we need to press to authenticate correctly?
Interacting with & About button to proceed.
A member is calling to make sure a cataract surgery will be covered. When you enter the policy page of the member, a Green Cross icon appears below the member's name. What do we do?
Is a MED SUP plan. We transferred the call to the Medicare Supplement department because we are not trained to handle these plans.
What C/I we use when a member is calling to let us know they have received their ID Card?
Communication-Got a Letter/Call
What benefit we quote when a member wants to check if a COVID-19 vaccine is covered?
Immunization.
If a member's representative is calling us to check benefits, and we are showing an alert, we could provide it?
If consent is on file or if verbal consent was obtained, yes.
Give me 3 different types of ID we are able to use for authentication. (Skipping the Humana ID & Medicare ID)
SSA
Medicaid ID#
Payment ID#
A POA on file is calling because they want to change the credit card information of the member to make payments. When we check on systems, the POA is a type U. Are we able to make changes?
Can the POA make payment method changes or request a spending card?
What C/I we use when a member is calling us to check how much has been placed towards their pharmacy stages?
RX/Accums
What does the 70-RAC status code on RX Nova claim means?
On what situations it's not appropriate to deliver or handle an alert?
In a hurry
Irate
Not willing or able to give consent
Termed
What happen when a caller wants to get PHI from the member's account, but member is not available to give verbal consent because the member is in a coma.
Identify the requestor’s relationship to the member and attempt to have them verify member elements. Document the special circumstances and release the requested information when the requestor reasonably matched the elements.
The son of the member is calling us. The son let us know that the member has passed away and he already paid his premium for the whole year and wants a refund because the member is not using the plan anymore. What mentor we follow to provide guidance?
Deceased Member Refund Medicare
What C/I we use when a member is calling us to see if a voice box is going to be paid by Humana?
Benefits/Verification.
Until what percent a member needs to reach so is able to have a refill for their medications as soon as possible?
What we select on the drop-down menu if previously a member already received the information of an alert?
Select Termed from the Action Name drop-down.
We are able to give out PHI information to the MEMBER if they don't provide the correct answer for the security question?
Advise the inquirer that PHI information can't be released nor the password reset without answering the secret question.
Member wants to know if a provider is in-network. The member is very confused on what their benefits are, and he is not very familiar with the plan he has for this new year. What cycle we need to do in every benefit call? Demonstrate
VOB Cycle
Quote benefits, check provider network, and make sure if any Auth/Referrals are needed (vice versa)
What C/I we use when a member's representative is calling us to let us know that the member has passed away?
Demographics/Report of Death
What benefits we quote when a member is having a drug administered by their doctor?
- Other part B drugs
- Surgery Services
If a member is due for a refill medication, and doesn't need a refill on their prescription, what is the process of handling the alert?
a. Advise the member of the importance of taking their medications as prescribed.
b. Complete the Medication Adherence Alert
- Select Delivered from the Action Name drop-down.