Pharmacy
What is LIS?
Low income Subsidy
Plans that require Primary Care Providers (PCP) to coordinate the member's care through a referral process.
Gatekeeper
What is a prospective member?
Individual who is not actively enrolled in any helath plan offered by UHC
Which JA can help us determine what intent/request type to use on Maestro if we are unsure?
Maestro Category Intent Request Type - Index
A denial must be on file prior to submitting this or the member must disagree with the processing or responsibility of a claim.
Appeals
What is the name of our Home delivery pharmacy?
Optum RX
What intent is used to compare current and new plans with the member?
ANOC change
What intent is used if a member calls in and wants to be reimbursed for a claim he/she paid out of pocket.
DMR(Direct member reimbursement)
What is the correct job aid for plan changes?
Plan Changes DT
___________ complaints are ones about services received by a member from a medical provider, medical facility, or pharmacy, which were inadequate or substandard in quality.
Quality of Care
What is generic?
The off brand for a medication.
A plan that does not require referrals.
Open Access
A legal document which allows the holder to act for the member (Grantor) in making financial and/or health care decisions
POA
Which job aid can we use to determine what we can update with a caller?
HIPPA-Index
What does MIOD stand for.
Member Initiated Organization Determination
What are the coverage stages?
Deductible, initial coverage, Coverage gap, Catastrophic coverage
What is EOB?
Explanation of benefits
What do you confirm when a member calls in and has not been authenticated?
Which decision tree can guide us through answering members benefit questions?
Quoting Benefits
Details of a complaint should include?
WHO, What, When, Why, Where, and How
Where can a member LIS level be viewed?(3 options)
Marx, Plan tab(under plan information), and Summary tab(under prescription plan tile).
What is balance billing?
Member being charged over their member responsibility on claim(s).
True or False: Authorized Representative can not submit a Sales Grievance without the members verbal permission"?
False
which job aid can we use if member is indicating they have concerns about their prescription costs to help member find cost saving options?
Rx Cost Savings
If the member has complaints about ancillary or supplemental benefits (such as dental, vision, hearing, DME, etc.), should the grievance be classified as Part C or Part D?
Part C