Case Outcomes & SOB
What case outcome is selected when all verified pathways are covered and no prior authorization is required?
What is Covered?
Before working a case, what tool is used to verify diagnosis codes are on-label?
What is the Product Overview Lookup Tool?
Question: What status should an agent use when information needed to complete a BV cannot be found after reviewing documents and call logs?
Answer: What is Missing Info Requested?
Question: What type of benefit covers doctor visits, hospital services, and provider-administered injections?
Answer: What are Medical Benefits?
Question: In a Traditional Medicare and Medicare Supplement combination, which plan pays first?
Answer: What is Traditional Medicare?
Question: What case outcome is selected when at least one pathway requires prior authorization or a formulary exception?
Answer: What is PA/FA Required?
Name one of the three Request Details agents must verify before working a case.
What is Network Type Request, Benefit Type Request, or Site Type?
Question: If a payer cannot locate the patient using the member ID, what two pieces of information should the agent ask the payer to search with next?
Answer: What are the patient's name and date of birth (DOB)?
Question: What does PBM stand for in pharmacy benefits?
Answer: What is Pharmacy Benefit Manager?
Question: What type of secondary plan does not pay if the primary plan already paid the same amount or more than the secondary would have paid?
Answer: What is a Non-Duplication Plan?
Question: What case outcome is used when all patient insurance policies have terminated?
Answer: What is Policy Terminated?
What tool should agents use to review payer-specific contact information, pushbacks, and requirements?
What is the National Payer Tool (NPT)?
Question: If a patient has met their Out-of-Pocket Maximum, what should happen to the product and administration cost-share amounts on the Summary of Benefits?
Answer: What is replace them with $0 while leaving the coverage blurb unchanged?
Question: If a medication is not included on an insurance company's covered drug list, what is it called?
Answer: What is Nonformulary?
Question: A patient is covered under both Medicare and Medicaid through a single Medicare Advantage plan. What type of plan is this called?
Answer: What is a True Dual Eligible Plan (D-SNP)?
Question: Name one reason a BV case may be closed as Created in Error.
Answer: What is a duplicate case, enrolled in error, management request, SOB mapping issue, or duplicate MDM ID?
When reviewing Care Teams, what type of site determines whether the agent calls on behalf of the treating site instead of the treating provider?
What is Hospital Outpatient (HOP)?
Question: How many attempts over how many business days must an agent make before reporting a plan as Undisclosed due to excessive payer hold times?
Answer: What are 3 attempts over 2 business days?
Question: What insurance term describes the fixed amount a patient must pay before the insurer begins paying for covered services?
Answer: What is a Deductible?
Question: How can you identify a Federal Employee Program (FEP) plan from the member ID?
Answer: What is the Member ID starts with the letter "R"?
Question: In an Injection Network case, the Summary of Benefits must be sent to how many sites?
Answer: What are both the Prescribing Site and Treating Site?
What section of the Patient Program allows agents to review previous call documentation across the case history?
What is View Call History Report?
Question: When a Prolia diagnosis code begins with the letters "C" or "Z," what type of case is it automatically identified as?
Answer: What is CTIBL (Cancer Treatment-Induced Bone Loss)?
Question: Which insurance plan always pays last when coordinating benefits?
Answer: What is Medicaid?
Question: When a BCBS representative says "Bill the Local," what does that mean?
Answer: What is use the claims address of the patient's local Blue Cross plan based on where treatment is being received?