GENERAL
Which of the following is NOT a responsibility of a PMG?
Member eligibility determination
Beth calls on March 15 requesting to change her PCP effective March 1 (retro request). The member confirms they already had a visit with a different provider on March 5, and now wants the new PCP to be applied retroactively. What is the correct action for the advocate?
Deny the request and follow the Standard PCP Change process instead
A member enrolled in a Gatekeeper HMO plan wants to see a specialist. Which of the following situations requires a referral from the Primary Care Provider (PCP)?
Visit to a specialist for evaluation of a medical condition causing hearing loss
A member had a specialist visit on June 10 without obtaining a referral. On June 16, the member contacts their PCP requesting a retro referral so the services can be covered. What is the correct outcome?
The referral cannot be retroactively entered because it is beyond the 5-day limit
TRUE OR FALSE: After completing a PCP change request, offering to assist with scheduling an appointment is optional.
False
Rebecca, who has been a patient of Pacific Medical for 30 years, calls after hearing that her longtime provider may be leaving the network. She is concerned about maintaining continuity of care but has not received any notification regarding a network change. What should the advocate do?
Verify in the Provider Contract Changes Tool, and assist the member with next steps
For California (COSMOS) Members: If a PCP change request is submitted on April 21, when is the effective date?
May 1
Roger is wondering why he was assigned a PCP that he did not choose. Upon review, the advocate sees that no PCP was listed on the member’s enrollment form.
Roger is wondering why he was assigned a PCP that he did not choose. Upon review, the advocate sees that no PCP was listed on the member’s enrollment form.
A member reports that their provider’s phone number and specialty are incorrect, and the provider has already retired. The advocate confirms this needs to be reported in Maestro. What is the correct process the advocate should follow?
Click Add Task, select Search and Assign Provider, launch search, select the provider by name, scroll down to Report Incorrect Information, and complete the required fields
A member reports that their provider’s phone number and specialty are incorrect, and the provider has already retired. The advocate confirms this needs to be reported in Maestro. What is the correct process the advocate should follow?
Click Add Task, select Search and Assign Provider, launch search, select the provider by name, scroll down to Report Incorrect Information, and complete the required fields