Gathering Basic Information
What is HIPPA and when do you verify it?
HIPAA is obtaining first and last name and dob...should be obtaining on every call before releasing any personal information.
The agent must identify the consumer's ___, ___, and ___they prefer to see to confirm their network status
PCP, Specialists, and Facilities (High Point)
What are the 3 prescription coverage stages?
(Initial Coverage, Coverage Gap, Catastrophic Coverage)
Obtain clear "yes" or "no" responses
If customer service confirm that HIPAA has already been verified (on a call transfer), does this satisfy the HIPAA requirement?
Yes
For PPO plans...what must you advise the consumer if the provider is out of network?
"Since the plan offers out-of-network benefits, we will cover the provider out-of-network as long as they are willing to accept the plan."
What amounts count toward the Initial Coverage Limit?
What the consumer pays plus what the plan pays toward the consumers covered drugs
What process must you follow for a witness completing an application?
If Applicant + Witness:
*Have the applicant provide their First and Last Name + Date of Birth plus state the witness's First and Last Name.
*Read the 'Witness' question verbatim from the LEAN application and have the applicant provide a clear "yes" response. If the applicant says "no," they must complete the enrollment themselves or call back later with someone they are willing to have assist with the enrollment.
Note: When a witness is assisting with the enrollment, the consumer must be on the line for the applicable portions, including:
What contact information must be obtained from the consumer?
Obtain or confirm telephone number and email address
If hospital, urgent/emergency care, or facility is discussed what must you also advise the consumer of?
If hospital, urgent/emergency care, or facility is discussed with the consumer, provide accurate facility copay/coinsurance information. (HIGH)
If the consumer identifies a ___ ___, the agent must provide an accurate explanation of plan coverage
Specific need
What is the IRMAA threshold for 2020
$87,000 for individuals and married couples filing their taxes separately, and $174,000 for married couples filing their taxes jointly
What information must you obtain from a third party (including Auth Rep or Witness) prior to releasing any personal information?
-First and Last Name + Relationship to applicant
-Applicant's First and Last Name + Date of Birth (HIPAA)
For an existing consumer switching from one MAPD to another MAPD, are there any exceptions to rx look up requirement?
If the consumer is a current member switching to a plan with the same formulary, you only need to look up medication coverage if the member requests.
If a drug is not covered by the plans formulary, what can you suggest to the consumer?
Formulary alternative or physician can request a formulary exception
Can you use the plan change scripting when changing a member from an HMO to HMO-POS and vice versa?
Yes
If a consumer calls stating that they no longer want or are no longer receiving group retire benefits, however are flagged Employer Group Retiree what process do you follow?
Agent must route the call appropriately to the Group Retiree Telesales line.
*Exception: If the consumer is a Railroad Retiree, Individual Telesales Agents are allowed to complete the enrollment without transferring the caller.
What are the 5 medication utilization management restrictions?
Quantity Limits (QL), Prior Authorizations (PA), Step Therapies (ST), 7 Day Limits (7D) or Dispensing Limits (DL)
Define Step Therapy
There may be effective, lower-cost drugs that treat the same medical condition as this drug. The member may be required to try one or more of these other drugs before the plan will cover the drug. If the member has already tried other drugs or the member's doctor thinks they are not right for the member, the member or the member's doctor can ask the plan to cover this drug.
Can you use the plan change script if changing the consumer from the UHC Medicare Gold RPPO to the UHC Medicare Silver RPPO?
No...the plan change reduced scripting is not available to use for DSNP or CSNP plans