CTU Jeopardy

HIPAA

100

Needed for authentication on every call.

What is 1 Primary and 2 Secondary's Elements ?

200

123-45-6789A

What is the HICN (Medicare Number)?

300

You use this as a last resort for locating a member in the system

What is name and DOB Search?

400

What we do when a 3rd party calls in

Is the member aware that you are calling on their behalf?

500

We cannot provide this info to the Retail Pharmacist

Effective and Term dates for a PA.

MedHok

100

This is needed when sending out a fax for the person who called in for it.

Place the ATTN:(Name) in the who field on the fax.

200

This is to be used as a last resort for a fax form

SSI Model Form in Medhok.

300

This is where you will find the PA's that have already been sent in and or worked.

Under the Case tab

400

We use this tab when we need to send out previous letters out to MDO and or members that may need another copy.

Correspondences Tab

500

DOUBLE POINTS! We do this when we cannot find the correct form to send out. ( I need steps in correct order)

1. Get the NDC number of the drug needed 2. Right click on the Case Tab and click ADD. 3. Paste the NDC in the Fields and take out the dashes. 4. Click on the ? next to pending 5. Take the name off of the top of the tab and send out the form.

Test Claims

100

Use this screen to find out info on the drug.

Drug Information screen

200

Use this number to already pull up the drug that was already ran by the pharmacy in the test claim.

Dispensed ID

300

Quantity Limit __ PA Needed __ Step Therapy __ Tier Exception __ Non Formulary __

76 75 75,76 N/A 70

400

Rejected claims and rejected test claims may show both a Settlement Code indicating that plan limitations have been exceeded and an informative Settlement Code indicating what the plan limitation is. (True or False?)

True

500

Place the following steps in the correct order for correctly calculating the quantity of non-tablet/capsule medications. (Number each step

1_ Find out how many total uses are needed per day. 2_ Calculate how many total uses are needed for the day supply. _3_ Divide total uses needed for day supply by the “Usage Qty Pkg”. If the result is not a whole number, round up. _4_ Multiply the total number of packages needed by the package size

Anything

100

According to CCF Step 5 (Closing Your Member Experience), you should ask a ____________ question.

Resolution

200

Examples of PHI include: (Select the five that apply)

Plan Member Names Plan Member Birth date Plan Member Telephone #s Plan Member ID# Plan Member Address

300

Use this tab in PeopleSafe to see PA info for ones that have been sent in.

Plan Benefit Override (PBO)

400

The 3rd Party that handles 2nd level Appeals

Maximus

500

Using the related work instruction as your guide, place the following steps in the correct order (1-5) to edit a task you've created.

_1_ Select the Resolution Manager tab _2_ Select the Cancel/Edit task tab _3_ Select the hyperlink of the RM Task to be edited in Task Details _4_ Make edits to the task _5_ Select Save

PeopleSafe

100

David Jones has called about his prescription benefits. When you look up his member eligibility status in PeopleSafe, a NOT ELIGIBLE indicator is displayed. How should you communicate this to Mr. Jones?

Mr.Jones I need to Transfer you to customer care for further resolve.

200

What we do when a Fallon Member calls in or After Hours (Need Details)

Place a RM task. Able to describe the process.

300

Indicate where you would click to access information for how a plan handles Prior Authorizations, Plan Benefit Overrides, and Appeals.

CIF hyperlink to CareSource

400

DOUBLE POINTS!! This is the Log Activity code needed to be used every call.

1011 PA

500

After performing a Test Claim, where would you click to see the Test Claim Results screen, which displays the Settlement Codes to assist you in the Test Claim interpretation?

Details link