Medicare
When you take on UHC what parts does members get
PT A, PT B, PT C, PT D
What is the 3,5,6 Rule?
The levels of Medicaid that does not pay costshares?
How is Maestro opened?
From inside GEN once it is launched
If member is IVR verified, what info do you have to verify to be HIPAA verified?
FULL NAME
What is a grievance?
Member says they are dissatisfied, angry, or this is the third time they have called for the same issue.
What doe M&R stand for? What is the parts of Original Medicare?
Medicare and Retirement, PTA and PTB
What is a cost share?
Copays, coinsurance, deductibles.
What is name of intent that you assign an AR or POA?
Manage Auxiliary Persons
When member is not on line and you cannot see that there is an AR on the account what is your next steps? What type of caller is this?
Tell member basic information and that member can go online, call in and add them, or call us and we can mail out the form to add the caller. Third party
What two types of Grievances do we have?
Verbal Grievance (VG)
Quality of Care Grievance (QOC)
What is the portion Medicare pays called?
Medicare Allowed Amount
Is Medicaid State or Federal? What 2 things do we use Medicaid for to assist our members?
State. Verify coverage for Cost Shares and warm transferring members with PTA and PTB help (social security or Medicaid)
What intent do you file a Grievance in?
Complaints Appeals and grievances intent. (CAG)
What do you gather in a basic HIPAA verification?
3 of these: Name, DOB, Member ID/MBI#, address
What is 3 standard of care issues that would warrant a QOC grievance?
Varies
What organization organizes and manages Medicare?
CMS
What is the difference between Medicaid and LIS?
Medicaid is state and LIS is federal (social security) Although they are both extra help you can have LIS and not qualify for Medicaid.
When scheduling a retro PCP change what would be the date? 12/01/2023 or 11/01/2023.
11/01/2023
Where does HIPAA go in the call flow?
After AWE statements or before.
What is your main Grievance job aid that branches into your Grievance Categorization Job Aid?
Grievance Handeling
When taking calls if member states they are having 160 something from their account deducted what is prob going on?
260 something?
PT B
PT A
What 3 resources do we use to verify Medicaid in order from most accurate to least?
Marx, DMEVS, and Maestro
When you have someone that has seen their current PCP in the month, they are changing it do you do a retro PCP change or a standard? Which one do you read the statement in Maestro?
Standard, Standard
If a caller is a Provider what information would you authenticate? What can you do and what can you not do?
Member 3 points
Caller first and last name one of the following: Tas ID, NPI/NCPDP#
Provider first and last name
Name of facility
When we file the grievance where does it go?
Are they responsible for resolution of that complaint?
A specialized internal team
NO. Resolution is with you