Intent
What intent would you use if someone is calling in about a medical Claim
Medical Claim history
where would you find where a POA sends paperwork
Auxiliary Persons - Address and Fax Number
True or False. There is no need to open a members account when they are calling about a general inquiry ie; a phone number
False
Member is upset they have not revived renew rewards card. what type of VG is this?
Plan/reward and incentive program
True or False. Emails should be checked periodically through the day.
TRUE Any email sent to you should be opened. also Jessie hides hidden messages in emails they could be anything from a fun fact to requests for you do something
Member would like to enroll in paperless statements what intent is used?
Update member profile/ Update Member Preferences
what JA would you use to see what a non member caller can and can not do on the members account
HIPAA - Index
What is needed to Hipaa Verify someone?
First and last name
DOB
Member ID or Member address
When Filing a OD and the medication is generic would you put that substitutions are allowed?
Yes. because the medication is a generic brand it can be substituted for another generic or name brand of the medication.
Who do you contact for Intradiem issues?
Open a Help Desk ticket through Sparq
Member calling in to check benefit for out of the country coverage where would i look for this?
Review Medical Benefits
Member had progressive for medical claims when they was in a accident in 2021 they are no longer using them however got a letter stating that claims are denied as they should be going to progressive
Medical Coordination of Benefits - Index
Where would you find if a Bra would be covered and what the benefit would be for someone who had a mastectomy?
Coverage summary
While filing a VG and a member was calling in did not receive his ID card by the time his plan started what information are you putting in the resolution?
Apologized to the member,
Verified the address we have on file is correct
offered to resend the members id card Member agreed to this.
S CASE number where you sent ID card
Advise they can see the ID card online if they would like until the cards arrive
True or False: If you Aux anything other than ready break and lunch you don't need to enter it into IEX
False always put anything you Aux other than Ready lunch and break in IEX
What intent are you using to file a OD
CAG
For first-time Balance Billing requests: Answer the questions appropriately in Maestro and use the process within COSMOS Navigation - Macro to launch the balance billing macro to send a cease billing letter
Claim Inquiries - Educating Provider on Balance Billing Issues - Tier 1
Member is calling in for a service that is not covered and has said they would like it to be covered. Is this something we can offer?
Yes it would be a CD
AR is calling in Member is in a SNH and has not been fed in a couple days. What type of VG is this and can the AR file it?
QOC YES
True or False You should always be checking your teams chat and side chats.
True. If someone is sending you a side chat usually its important.
What intent is used to see if a medication is covered by the plan
Formulary
where do you find how to categorize a grievance?
Grievance Categorization
Aretha Franklin is calling in for her grandpa Joe she has all of the information on grandpa Joe to verify him however she is not a AR on the Joes account. She is calling in to ask about benefit information can you assist Aretha?
YES, basic plan information can be shared with anyone asking for it even if they are not a AR
S CASE NUMBER
if a provider make sure you always tell them and notate they never have to go back to that provider if they don't wish to