Grievances
Enrollment
Claims
LEP
Authorizations
100
Grievance Resolution Timeframe 

What is 30 calendar days?

100

Enrollment periods 

What is Initial coverage election period, AEP and OEP

100

Member Cost Share

What is Copay, Coinsurance, Deductible 

100

what does LEP stand for and the meaning

What is Late Enrollment Penalty is permanent and applies for all Medicare plans. It is a penalty on individuals who do not maintain creditable coverage for a period of 63 days or longer following their initial enrollment period for the Medicare prescription drug benefit or a subsequent gap of 63 days in between one coverage to another. 

100

Authorization vs Referral 

what is 

Authorization — An agreement between Anthem and a provider that a specific service for a specific member is medically necessary. Authorizations have a beginning and an end date.

Referral — A referral is when a member’s PCP feels their medical condition requires them to see a specialist. The PCP will give the name of a specialist/facility they recommend the member see or go to, and will advise the specialist that they are referring the member to them. A referral is not an authorization issued by Anthem. Click here for additional PCP and specialist referral talking points.


200

Type of authorization form for a grievance

what is AOR- Appointment of Representative 

200

the teams that handle enrollment and plan changes 

what is HPA and Loyalty 

200

Member Submitted Claims turn-around time 

what is 60 Calendar Days 

200

Creditable Coverages

  • Drug coverage from a current or former employer or union
  • TRICARE
  • Indian Health Service
  • Department of Veterans Affairs (VA)
  • Individual health insurance coverage
200

Pending Authorization meaning 

what is  an authorization that has been entered into Compass and the pend code has been added to the authorization to prevent claims payment for a specific action. The action needed could be additional clinical, case rate negotiation, etc. 

300

When to file a grievance 

What is any time a member expression of dissatisfaction with any aspect

300

OSB enrollment period

What is during AEP, or within the first 90 days of their plan effective date. 

300

when a member disagrees with cost share 

what is appeal rights 

300

Attestation timeframe with insurance 

what is If attestation not received within 30 days of the date of the letter, the LEP will be assessed but the health plan has 60 additional days to remove the LEP 

300

Timeframe for standard authorization 

what is 

  • Standard Medical:  14 calendar days


400

Where to find a resolution 

what is Dochub/Macess or VAM 

400

OEV Letter

What is Outbound Enrollment Verification members may have an additional period to cancel their plan after the effective date 

400

Where to find a DOFR

What is 

Compass > Composite screen > Member Info tab > PCP Section > Double-click current PCP > scroll down to “Delegated Risk Information” section > Press “View DOFR” button


400

where are LEP letters housed 

What is Medisys 

400

where do to check to see if a CPT code needs authorization 

What is Pluto

500

 3 types of grievances that can be sent to MCAG

What is Access to Care, Quality of care and Broker misrepresentation?

500

SEP Qualifications

what is Dual eligible, address change, employer plan change, disenroll from Part D to enroll in Creditable Coverage, change in LIS level, chronic condition 

500

How to find the MOOP in compass 

what is 

  1. Click on the Medicare Info tab in the Member Composite Screen
  2. Click on the magnifying glass to the right in the Accumulators section
  1. Select the requested date range from the Coverage Period drop-down


500

C2C

What is the dept to appeal an LEP after the 90 days 

500

what does Carelon PAS handle 

what is Home Health, Post-Acute Care, SNF, LTAC, Inpatient Management and DME