Kelsea's Trivia!
Once a member loses Medicaid eligibility, how long is the grace period?
6 Months
A request to have the plan cover a specific medical service. Examples of this are:
What is an Organization Determination (OD)
Initial processing of a claim submitted in to the insurance plan takes how long to be processed?
What is 30 Days
These are types of callers that can complete an NBA.
Who are Members, POA's or Authorized Reps?
Another way to say "Stop billing the member".
What is Cease Billing?
How many initial outreach attempts are navigators able to make to a member?
There are no limits to the number of calls made to a member.
What details should a Grievance include?
Who: Who is the complaint about
What: What happened and Why is the caller dissatisfied.
Where: Where did the issue happen
When: When did the issue happen
When a provider (Doctor/Hospital) bills a member more than the plan’s allowed cost-sharing amount the plan says they must pay
What is Balance Billing
These are the steps you take when an NBA is started and is unable to be completed fully.
What is cancel it and document why it was not completed?
This service is $0 copay for members when provided by INN providers only, and is essential to ensure members lead the healthiest lives possible.
What is Preventive Services NBA's?
Members have ____ options available to them to access/utilize their UCard benefits.
A. three
B. four
C. two
D. five
B. Four
Quality of Care or Standard Grievance?
1.)Transportation was late or did not arrive for a scheduled trip to a pharmacy, resulting in the member being unable to get their medication and they are out of their medication(s)
2.)Waiting less than 30 minutes beyond scheduled appointment time to see provider, is seen
3.)Pharmacy or pharmacist refused to fill prescription
1.) QOC
2.) Standard Grievance
3.) QOC
When a patient or a provider tries to convince an insurance company to pay for health care after it has been decided not to cover costs for a claim.
What is an Appeal
This NBA helps determine whether a member may need additional assistance from resources outside of their health plan.
What is Social Determinants of Health?
A new digital platform that personalize your journey empowering you to build skills and developed skills for your current work and your future career.
What is "My Learning"?
Member calls in stating they received a notice of denial of payment on a claim. The denial reason shows that the member has another primary insurance listed. This issue is known as ____.
COB (Coordination of Benefits)
True or False: Housecall Grievances, we do NOT document the housecall practitioners name or the representative.
False, we do document the housecall practitioners name but not the call representative.
A prescription claim that moves through more than one benefit level such as initial benefit to coverage gap when adjudicated
What is crossover Claim
One of the things this NBA educates members on is Rx Home Delivery.
What is 30-Day to 90-Day Refill, 100 Day Supply, or Home Delivery Refill?
This is the connection between the emotions and behaviors that affect a person's overall well-being.
What is behavioral health?
There are certain C&S states that do not have a reprint option available in Doc360. The only states that do have the reprint option available are Indiana, Kansas, New York, Missouri, and ____________.
Maryland
Member waited to be seen for 25 min at provider's office.
What category would be used?
Provider/facility service (no actual or potential impact to care)
A fraudulent practice of ascribing more than one code to a service or procedure on a bill or claim form when only one is necessary.
What is Unbundling
This Preventative Services NBA assists members who have Diabetes.
What is the Diabetes A1C Blood sugar PCP office visit?
Delivers care aided by technology and data, empowering people, partners and providers with the guidance and tools they need to achieve better health
What Is Optum?