SOPs
Fill in the blank
Medicaid ____box
Medicaid toolbox
A denial MUST be on file prior to submitting an appeal.
True or False?
TRUE
Compliance One Source (Medicaid) - Appeals and Grievances
KM1263570
important note
PCP changes can be done be us SMEs?
True or False
TRUE we can complete PCP changes.
For member: JEAN MILLER
Subscriber ID :116584371
Why was ROSUVASTATIN TAB 20MG denied on 08/21?
Surplus Limit 20 has been met/exceeded. Next Fill Payable on or after 08/30/25.
What system do we use to update PCPs?
FACETS
What SOP do we use for PCP updates? (Medicaid)
Search and Assign Provider Intent (Medicaid)
KM1273654
What system do we use to view appeals and grievances?
(NOT MAESTRO)
ATS
What is the change limit for NY Medicaid member PCP changes?
New York members may change their PCP a maximum of three times per year without cause.
What system do we use to flip COB flag for pharmacy issues?
NEXTGEN
WA Medicaid members can receive a car seat at no cost, and pick between 2 car seat models.
True or False?
TRUE
WA Medicaid - Value Added Benefits
KM1915358
What SOP lists all state specifics for Medicaid transportation information?
Transportation (Medicaid)
KM1236005
If a PA Medicaid member states they want to submit their grievance in writing, what address would we provide?
Compliance One Source (Medicaid) - Appeals and Grievances KM1263570
ONLY provide the written process if the caller opts to submit in writing.
For RI Medicaid members who frequently change their PCP (changed once or more per month unrelated to address change) what process would we follow?
f frequency is occurring in CSP under eligibility tab click on Show History and check if PCP has been changed once or more per month and the reason is unrelated to an address change, send an email to: Kelly Earl and Pam Ruzzo.
KM1273654
Lost/Spilled or Vacation Overrides in TEXAS are not allowed.
True or False?
Pharmacy - Pharmacy Overrides (Medicaid)
KM1230361
TX
LOST, SPILLED MEDICATION, AND VACATION OVERRIDES ARE NOT ALLOWED. An early refill may be granted by having the member’s physician contact the Community and State Prior Authorization team at 800-310-6826. No controlled substance overrides will be allowed.
If a member disagrees with the end date of their Medicaid plan, what would we advise?
They need to contact the state/ Medicaid office if they disagree with their end date.
What SOP do we use for Medicaid member A&G?
Compliance One Source (Medicaid) - Appeals and Grievances
KM1263570
For NC Medicaid members, what is the TAT for UHC to issue a decision for an expedited appeal?
UnitedHealthcare will issue a decision within 72 hours by phone or fax, and mail the Decision Letter within 2 calendar days.
Note: There is a possible 14 calendar day extension if additional information is needed.
Start with:KM1263570, appeals tab, NC, then takes us to KM1265652 , quick links TATs.
HEATHER L BANTA Subscriber ID :104880215
Member wants to update her PCP, based on the providers contract can we assign this pcp?
Provider ID: 002474179002
KARETNICK, GERALD D.
We can not assign PCP because contract is termed for CAID as of 08/09/2023.
For NY UHC Medicaid members, effective 04/01/2023 what is the pharmacy vendor?
Effective 4/1/2023: NYRx
The NYS Medicaid Pharmacy Program Helpline
800-541-2831 (Mon-Fri 8AM-8PM; Sat 9AM-1PM)
Other than ICUE, what system can we use to verify if a Medicaid member has a case manager?
Community Care.
Member ID if class wants a walk through:132381312
What SOP do we use that provides guidance on how to notify the plan or state that the member is deceased for Medicaid plans?
Medicaid Deceased Member Notification
KM1261800
According to Compliance One Source (Medicaid) - Appeals and Grievances can we (SMEs) file a 2nd level grievance for members?
NO, Do not use - applicable to the A&G team only
under maestro action steps in KM1263570
Share your screen and update the members PCP. WITHOUT CLICKING SAVE
ALFONSO SAVASTANO
Subscriber ID :110762752
Member wants to update the PCP to
Donna Marie Koch, DO
Provider ID: 001996329001
Effective 08/27/2025
:)
If a AZ Pharmacy Lock in member needs a temporary pharmacy location override, what SP would we use?
Pharmacy Lock - In Client Service Requests Form.
A NY Medicaid member is calling to request a proof of loss coverage letter, would we provide this to the member?
NO, letters for NY Medicaid will be sent directly through NYSOH.