Tags
MM wants to know the status of their prior authorization
What is prior authorization?
The type of escalation we create when a MM does not have a bill generated.
What is an EL escalation?
We need a CPT code to provide a cost estimate.
What is false? We can look up the estimate via procedure name as well
What we teach the MM when they call to make a payment.
What is online payments?
The priority for a call where we need to escalate to Eligibility.
What is major?
MM wants to know the difference between the deductible and MOOP.
What is Benefits?
3 types of information we document when a third party is calling on the behalf of the MM.
What is their name, relationship, and callback number?
We do not need to document a call if it's short and minimal information was exchanged.
What is false? Every interaction should be documented if information was exchanged. We do not need to document if no one is on the other end or if the MM immediately gets transferred.
*context of the call* The MM is frustrated because they have to keep calling to find INN providers.
What is the care router?
Name one thing we should be telling MM's when they mention they are going to their doctor for an annual physical.
What is Quest labs? What is preventive vs diagnostic? What is they must seen an INN provider? What is annual physicals are free?
MM needs assistance in logging into their web profile as well as inquiring about the status of their ID card
What is Website or App Issues & Other?
List out the steps in the Optum Workflow when the MM tells us they want an INN psychologist
1. Initiate conference call
2. Introduce yourself
3. Takes notes - view the documenting MM interactions Confluence page to see what we should be documenting
4. Tag ticket
Responsible Party calls on behalf of the MM to talk about their benefits. We correctly create the ticket under the RP's R#.
What is false? The ticket should be under who the call was about.
*context of the call* The MM asks us when her ID card will be delivered.
What is the digital ID card?
The 3 states MMs cannot use Doctor on Call
Where is Arkansas, Idaho, and Delaware?
We place an OBC to the MM to advise them that their claim has been adjudicated as in-network. During the same call, the MM asks us to help him find an INN UC.
What is Emergency Room, Is going to seek medical care, & Find a Doctor?
The steps we take when an off-exchange MM advises us that they need to change their address on file.
What is confirm if the MM's new zip code is within our coverage area?
MM is in collections for a balance bill. The appropriate priority for the claims escalation is major.
*context of the call* MM got billed last year for an EKG during her annual physical.
What is the preventives page?
Who is a nephrologist?
What is a specialist who specializes in kidney or renal issues?
MM calls in upset and crying that she has not yet received her step rewards because she was counting on the money to pay for her son's birthday gift. After we assist troubleshooting, the MM wanted to know if chiropractic care is covered. We tell her it is and that it is a $20 copay each visit.
What is General Grievance, Is going to seek medical care, Step Rewards, & Benefits?
List the 4 steps of the "Considering an ER visit" workflow.
What is
1. Advise the member 'If this is an emergency, hang up and dial 9-1-1'.
2. Provide in network ER options, review ER coverage policy and member's deductible/maximum out of pocket.
3. Find a nearby urgent care and mention the cost and types of issues treated there.
4. Offer to connect the MM to Doctor on Call as a free option that treats similar issues and is a good way to see if going to the ER is necessary.
NY Circle Plus MMs can see providers in Florida.
What is false? They need to by NY Circle Plus MM's with the OOA addition. Check their Rosco page to see if they have OOA coverage!
*context of the call* MM wants to keep track of their EOBs to ensure she is not getting over charged.
What is the claims page on the MM's web profile?
Text expander for grievances
What is *gr*?