Systems
The system used for RSS documentation.
What is GPS?
The providers with this status cannot be updated on the customer service side and would require the doctor to connect with network management for credentialing.
What is Closed status?
JA: Provider Participating Status Update
PI: RSS - Primary Care Physician Changes
EA Double Jeopardy!!!
Choose your Wager!
Who makes the decision on Part D second level appeals?
When granting temporary coverage due to Part A and/or B termination, after routing to T3, T2/RSS would update this system.
What is RxClaim NextGen?
JA: M&R NextGen Index
This is the formal process where UnitedHealthcare gives a contracting Medical Group/Provider the responsibility and authority to perform specific functions on its behalf.
What is Value Based Care Arrangement, formally known as delegation?
JA: Value Based Care Arrangements - Index
We use this System/Process with a "dad" name to submit an escalation to request for medical COB to be verified.
What is JIM?
PI: RSS - Medical Coordination of Benefits (COB)
Member called because claims from their doctor's office are being denied due to the plan showing the member has commercial coverage. The member retired last month. This is the PI that would be used.
What is RSS- Medical Coordination of Benefits?
The member is new to the plan and has requested something that shows how much their premium amount is. T1 called us to request this.
What is Premium Amount Verification Letter?
JA: Premium Payment - Premium Amt Verification Letter Requests
PI: RSS - Premium Amount Verification Letter Request
Good cause reinstatements only apply to these plans.
What is PDP?
JA: Good Cause Reinstatement for NPOP Members
PI: RSS - Reinstatements
Member has a prescription drug that was Rejected at the pharmacy because it was non formulary. What would we direct T1 to do next?
What is request a CD (Coverage Determination)
JA: Initiating a CD Request KM1004652
EA Double Jeopardy!!!!
Choose your Wager!!!
Who has all the rights and responsibilities of a member in filing a or dealing with any levels of the appeals process?
The member was recently married and therefore has changed their last name. 1. We must check this system to determine if we can make the update. 2. We update in this system.
What is 1. MARX and 2. GPS?
JA: Incorrect Name - Gender - Date of Birth
PI: RSS - Name Gender or Date of Birth Updates
Someone other than the member is requesting a refund for a member that passed away. This process should be followed.
What is JA: Refund Requests - Notification of Death and/or PI: RSS - Premium Refund Requests?
We must verify ______ before generating/providing a fitness code.
What is the vendor?
JA: Wellness Benefits - Index
EA Double Jeopardy!
Choose Your wager!
If the member received a NOMNC, who files their appeal?
The system that is the point of truth for employer group plans.
What is the GRIF?
JA: Employer Groups - Index
T1 called T2 because the member passed away 2 weeks ago and we don't have the TRR 90. When would RSS assist?
What is when the MOP if EFT?
JA: Notification of Death - TRR 90 Code Not Received
PI: RSS - Notification of Death
Member requested SSA and is showing Billing statement in Maestro but in Marx is showing SSA. This is the PI used to complete that update.
What is RSS - MOP Changes - Change to Match MARx?
The member submitted a new application that is pending for special handling because the member currently has a past due balance on their active plan. This is the process to refer to.
What is RSS - Application Status - Missing Information?
T1 calls for assistance reading a claim that was processed/paid and recently was reversed. RSS would refer to this PI.
What is RSS- Claims> RSS - Claims - Adjusted Claims?
After finding the FLN # in the ORS Contact History in Maestro, we can pull up a DMR that was sent to UHC from the member in this system.
What is Doc360?
JA: Doc360 User Guide
T1 called because the NICE member's doctor is not showing the member as active in the provider portal. We verify in 1._____ and see that the member doesn't have an active timeline. We will have to submit the update on 2. __________ _________ ________.
What is 1. ICUE and 2. Reconciliation Workorder Request?
JA: Member ICUE Eligibility Issues
PI: RSS- Member ICUE Eligibility Issues
These are the differences between an Account History Letter and a Total Premium Paid Letter.
What is the Account History is a monthly breakdown of the member's premium/payment for requested timeframe. Must be request through the Work Queue.
The Total Premium Paid is used mostly for tax purposes, says just how much the member paid for the set timeframe and is request in GPS/CCP letter writing tool.
PI: RSS - Account History Letter Requests
T or F: We can change a member's telesales agent to a different one as long as there is a previous application from that telesales agent's ID.
What is False? We cannot change from one telesales agent to another, only updating from telesales to Medicare Exchanges.
JA: Medicare Exchanges - Verify and Update Agent Record Process
PI: RSS - Updating Agent of Record
Extra info: Broker Sales Agent ID Lookup - Transfers
T or F: RSS assists with Medical COB, EOB requests, passport issues, timeline issues, RX COB, Claim issues, Requests to Void and Reissue Checks and Plan Directed Care.
What is False? RSS assists with Medical COB, EOB requests, passport issues, timeline issues and Claim issues.
PI: RSS - Claims