Rejection Codes
Rejection code 50
Out-of-Network Pharmacy or no Pharmacy Benefits
KC Best Practices: Be specific
How do I update a provider's address?
Name 3 verbal grievance catagories.
Customer Service, Fulfillment, Sales Agent, OTC, Pharmacy, Plan, Provider and transportation
What is Synapse Health and what is inscope?
DME provider that provides
If member calls in about a COB and their are no claims what intent do you use?
Update member COB intent
Rejection code 64
Claim Rejected due to not matching Prior Authorization
What would you avoid when trying to search in KC?
Abbreviations or short hand
What is a QOC?
Quality of Care
What is covered with OTC?
What are the steps taken for denied claim due to self administered drug while admitted into the hospital?
Offer member the direct reimbursement form
Rejection code 69
Claim Attempted after Coverage termination
How do we refine our search in KC?
We can use tags located in the left panel
For Part C Appeals what is the address and turn around time?
Appeals & Grievance Department
P.O. Box 6106
MS-CA 124-0157
Cypress, CA 90630-0016
What is the referral requirement?
Effective January 1, 2026, all Gatekeeper plans will require a PCP referral for specified specialist and outpatient services. Claims may not process or pay correctly without a valid referral.
What do we do when a member is requesting more transportation?
MIOD
Rejection code 83
Duplicate paid/Captured claim
Which search would populate the best results?
Using action words would populate the best results
What is the difference between a CD and a OD?
The CD is for part D coverage and the OD is for Part C coverage.
What happens to a referral if a member changes their PCP?
If you change your PCP and are already seeing a specialist, you can continue care covered by an existing referral. However, if you need additional services or future visits, your new PCP must submit a referral before those visits occur.
If member calls about a claim and we cannot see the claim who do we call?
PMG provider
Rejection code 17
Missing or invalid refill code
If the results are not suite right what else can you do?
Try Rephrasing
What do we put as the MIOD number if we do not get a confirmation email?
Send notification to supervisor with member information and put repeating numbers in the confirmation number section. Example: 999999
What doesn't require a referral?
What is considered a lifetime or limited service benefit?