Maestro Documentation
Member calls to discuss plan benefits. How would the advocate auto-document what benefit(s) were discussed on the call?
By clicking the box in the top right corner
Documentation Requirements SOP> Benefits
A provider called on the member's behalf to verify eligibility what intent would you choose?
Eligibility
A member is calling to check the network of a provider. What system(s) would you potentially access?
Maestro
Rally
Facets
PRE
Advocates should never document the names of other Customer Service advocates.
True
System Documentation - Appeals, Grievances, CD and OD>Who, What, Where, Why, When, How
What SOP would you access for pharmacy benefits?
Rx Benefits (IFP)
In general, what must be documented on all calls?
Who, What, and Where
Documentation Requirements SOP> General
A member is calling for assistance with scheduling an appointment with their provider what intent would you choose?
CSP Documentation- Appointment Scheduling
The member is calling to find out why their prior authorization was denied. What system would you access to find the denial reason?
I-CUE
The primary account holder is calling to discuss specific plan information for their spouse. It is not required to HIPAA verify the primary account holder.
False
HIPAA - Caller Types
What SOP would you access if a member is calling in regarding GAP exceptions?
Medical Prior Auth Call Handling (IFP)>Request Prior Auth or Gap Exception
You receive an escalated call (upset member) from a member requesting to speak to a supervisor. Per the SOP what must you document?
Escalate the call to the supervisor and document the following:
Escalated calls and Issues SOP> SEL Process
A member is requesting a coverage letter. What intent would you choose?
Member Materials
A member's mother is calling to check the status of their child's epilepsy medication. What system(s) would you access?
Maestro
PAS
Member calls in to verify behavioral health benefits, risk screening questions must be asked?
False
A member is requesting the TAT for a payment made via their member portal. Which SOP would you access?
Premium Payment Options and Issues - Index (IFP)>General Information
A repeat caller is calling for the same issue that has not been resolved. What information should be documented in Maestro
A member called to check on a prior authorization that their provider submitted what intent would you choose?
CSP Documentation- Pharmacy Prior Auth
A member is calling to check if a specific benefit is covered. What system(s) would you potentially access?
Maestro, benefit 360, doc 360
The member has met their deductible for the plan year, this means the member no longer has to to pay a copay.
False
A member is requesting a copy of their Medical EOB (Explanation of Benefits) to be mailed to them. Which SOP would you access?
Member Materials Request (IFP)>Medical EOB Information
If an appointment is scheduled for the member, what information should you document in Maestro?
Provider & Referral Call Handling Index - IFP SOP>Search & Assign Provider Intent
Member calls expressing dissatisfaction with resolution of a claim. What intent would you choose?
Appeals and Grievances
A member is calling to check the status of their appeal. What system(s) would you access?
Maestro
ATS
Acupuncturist providers does not require a referral for a gated plan.
True
Provider & Referral Call Handling Index - IFP>Referral Exemptions
An Off-Exchange member is calling to cancel their plan. What SOP would you access?
IFP Off Exchange Reference Guide>Account Updates/ Changes