Hip HIPAA Hooray
This is what we can provide when we are not able to verify HIPAA.
This is what MMR grievance stands for
What is a Marketing Misrepresentation (MMR) Grievance
How many days do members, their representatives, or doctors have to request an appeal from the date of the determination?
What is 60 days? (65 days starting in 2025)
Member service guides can make clinical or health suggestions for our members.
What is FALSE?
We should ALWAYS refer the member to their Primary Care Provider for a referral or guidance on any specific health question.
Do member'd receive an OTC catalog?
No, the catalog is only applicable for phone orders. Members will need to request a catalog by calling CVS.
PHI forms authorize Devoted to release information to a specific person, but if they want to take action on behalf of a member we will need this form on file.
What is POA (power of attorney)?
This is what you have to ask the sales agent for when they call in
What is an NPN
A member calls stating their prior authorization for a service was denied, and they want to appeal. They haven’t received the service yet.
• What type of appeal is this?
• How can this appeal be submitted?
What is a Pre-Service Appeal?
What is a verbal appeal?
NEW! In 2025, D2Me visits can be in person!
False: No, they're video only.
A member enrolled in February asks if they can still use their February allowance in March.
• Is this allowed? Why or why not?
What is yes, because the first enrolled month’s funds automatically roll over to the next month?
Do we need to re-verify HIPAA on transferred calls?
For external transfers: Guides need to re-verify HIPAA with the member or authorized representative directly, even if the information was provided by the previous agent.
For internal transfers: Guides do not need to re-verify HIPAA if the previous agent confirms they have already verified HIPAA.
This is federal agency within the United States Department of Health and Human Services that administers the Medicare program
What is CMS?
A member wants to appeal a denied claim, but they don’t have a balance due for the service.
• Can they file a post-service appeal? Why or why not?
• If they have accessibility issues that prevent them from submitting a written appeal, what should you do?
What is no, because a post-service appeal requires the member to have a balance due?
What is send a case to Appeals & Grievances with the member’s information and appeal request for review?
If a member has 3 NBA flags on their profile guides should complete all of them.
What is FALSE? Guides should always complete the first NBA to present in the profile. Orinoco will determine which NBA is priority and will present that one first.
A member calls in March and asks if their March funds can be rolled over to April before the month ends.
• Can we process this request? Why or why not?
What is no, because rollovers can only be considered for expired funds, and March has not yet ended?
What is the member must call back in April after the benefit expires?
This is what must be verified when an Authorized Representative calls on behalf of a member.
What is
Obtain the correct quantity of HIPAA identifiers, three if inbound and two if outbound.
Obtain the full first and last name or the authorized representative as listed under the Care Team tab.
Obtain the relationship to the member as listed under the Care Team tab.
?
This is what Hipaa stands for
What is Health Insurance Portability and Accountability Act?
A member calls and states that their agent told them their specialist copay would be $10, but they just found out it’s actually $45.
• What type of grievance is this?
• How should this grievance be processed?
What is a Marketing Misrepresentation (MMR) Grievance?
What is submitting it through the standard grievance process and sending it to the grievance team for review? ( NEVER FCR)
Member's without D2Me flags can still schedule visits
True:
If the member doesn’t have a D2Me needed flag, warm transfer mos-inbound / mos-inbound-spanish
A member used their first-month automatic rollover earlier this year and is now asking for a reinstatement later in the year.
• Can this request be granted? Why or why not?
No, because members are only allowed one rollover per benefit year?
For outbound calls, if a member is skeptical about releasing information the member can do this.
What is hang up and call us back at 1-800-DEVOTED (338-6833)?
This is three metrics on NBA Melissa post on Tuesdays
What is Action rate, Rec Rate, and OSR
A member claims they never consented to enrollment in our plan and wants to return to their previous plan.
• What key information should you check before proceeding?
• If they are still in their cancellation window, what should you do?
What is checking the left pane of the member’s profile or the OEV letter to see if they are still within their cancellation window?
What is advising the member of their cancellation deadline and asking if they want to remain in the plan or cancel enrollment to return to their previous plan?
If HIPAA has already been verified during a call and someone new joins the conversation, We Do NOT need to take additional steps for HIPAA.
False:
If the person who originally verified HIPAA is still on the call, but a new person joins, we must document permission to talk with that new person.
This includes asking for their first and last name, their relationship to the member, and the member's authorization for the individual to join the conversation.
We can get this authorization from a consent we already have on file, or from verbal permission given by the member during the call.
A member has a replacement card and asks for their balance to be transferred from their old card to the new one.
• Should a case be created to request a balance transfer? Why or why not?
What is no, because balances are per account, not per card? Any remaining balance will automatically be available on the replacement card once issued.