SYSTEMS
What systems do we use for prior authorization status?
MEDCOMPASS/EVICORE
medcompass is used for most all authorization requests- Evicore typically houses authorization requests for complex imaging
What are PEAS?
P – Paraphrase
E – Empathy
A – Appreciate
S – Summarize
How long does member have to file a grievance / appeal?
KA3109 Grievance – 60 days from the date of the incident.
KA3110 Appeals – 60 days from the date of the denial for pre-service / date of the EOB for post service
What document is used to determine how a claim was processed?
EOB – Explanation of Benefits
KA2576
What are the 3 primary tools for locating in network medical providers?
GPS Find Care
DocFind (Aetna Website)
Smart Front End (SFE)
What systems are used to view documents the member has sent to us?
ECHS AND/ OR IOP
True or False:
We should address account alerts before we take care of the member’s reason for calling?
False
We should address member concern and address all account notifications and alerts before we close the call
What are the requirements for an appeal to be considered expedited?
KA2825
Members have the right to ask for an expedited appeal if they believe the 30-day standard reconsideration process could jeopardize their health, life or ability to regain the maximum function. This only applies to pre-service appeals.
When is it appropriate to send a claim for rework?
Claim rework should be sent if the claim was incorrectly processed by Aetna, not if member disagrees with claim outcome (that would be an appeal)
Rework should be filed in GPS KA3149, and only filed in HRP if there are issues with GPS KA2816.
Reach to claims helpdesk if you need help determining if a claim needs sent for rework.
True or False?
If a provider is listed in SFE (Smart Front End) it means they are in network with member’s plan.
False.
SFE alone is not sufficient in determining provider network status.
Use KA3907 and compare SFE network codes to member plan codes in the Benefit Network Mapping Grid
What system is used to check the status of an appeal or a grievance?
MEDHOK
How do you close a call?
Resolve close "I wanted to make sure you're satisfied with Aetna and that I've resolved everything for you today" let member answer then “Thank you for being the best part of Aetna, You can find many resources at our website aetna.com/Medicare After the call there will be a short survey about the service I provided – do you have time to participate in my short survey?”
“Thank you so much, have a great day and hold for the short survey!”
What is the difference between “pre-service” and “post service”?
Pre-Service – the service has not yet been rendered. (example: preauthorization denials)
Post Service – service has already been completed. (example: claim denial)
What should we do if we do not find the claim on file?
Ask all the probing questions to ensure we have the claim information correct. (DOS, provider name, billed amount, type of service etc)
If claim is still unable to be located in GPS or HRP we should call the provider office to ensure they sent the claim to us.
Claims can take up to 45 days to process.
How can we locate a dental provider?
We should use member’s EOC and use the link to dental provider search in dental section of EOC.
Find Care/Medical Search tools is not for dental plan!
Each member plan may use a different link for dental providers
What system is used to verify what Medicare Advantage plan a member is currently enrolled in?
MARx
What is needed to provide the Member ID over the phone? Please provide KA.
We must verify the Medicare number (MBI/HICN)
KA4044
What are the ways to file a standard appeal and what is the turnaround time for the appeal?
KA3110
Standard appeals can NOT be filed over the phone. They must be filed in writing or online at the member’s plan website.
If the member chooses to appeal in writing; we should offer to send them the appeal form using ONE Kit.
Standard preservice appeals have a 30 day turn around time
Post service appeals have a 60 day turn around time.
How does a member submit for claim reimbursement?
KA2778
1. Online via member website
2. Mail or Fax using the member reimbursement form
NOTE: Member has 365 days to submit reimbursement claim.
Reimbursement can take up to 45 days to process.
If approved payment is sent as a check attached to member EOB
What is required for a provider to be listed as a member PCP?
Provider must be INN and credentialed as a primary care doctor in GPS/SFE.
What system is used to send a disenrollment letter?
OBC+
What should we do if the call is disconnected unexpectedly?
We use KA2588
1. Report disconnect to supervisor immediately.
2. Attempt call back to the member (even if AHOD)
3. Complete the dropped call tracker form
4. Document accordingly
(the only time we will not call member back is if member purposely hung up due to being irate/frustrated – we will still follow other steps in these instances.)
Where are expedited appeals filed? What is the alternate way to file expedited appeals?
Expedited appeals are filed in Stars Central Portal, if we have issues with Stars, we file the expedited appeal using the Medicare Advantage Expedited Appeals Intake QuickBase form.
KA2825
What do we do if a member’s reimbursement check has not been received?
KA3002
Stop Pay and Reissue Check IF it has been longer than 45 days from the check issue date.
What happens if member sees an out of network provider?
Depending on plan services may not be covered OR member may be responsible for a higher cost share.