Programs
Claims come in at 30% coinsurance with no deductible and member must enroll in CAP.
What is Standard
What information do you standardly input into CSP to pull up a members claims information?
What is a member CHID or Cardholder ID
True or False - Cimzia is a 2 part payer
What is false
As of 2024 Cimzia no longer has a VCC program
Which 2 drugs on the calls vs data load state that if only paying $0.10 per claim outreach must be started to have member call MFGR to answer questions and obtain VCC?
What is Dupixent and Kevzara
What should we verify on a claim before approving payment?
What is Modifier, 30% coinsurance and eligibility
A deductible plan that will only apply to select members or clients. The members will be fulfilling their full deductibles prior to SOSP. Member may choose how they wish to fulfill their deductibles including using CAP.
What is Adapt
When a member has received no CAP but is denied due to maximizer what type of override is placed?
What is MFGR excluded override
True or False - If CAP is paying under $200 per claim , you can approve and place $0 override?
What is True
Anytime you approve a case for an amount under the true annual max or adjusted max where should you place that information?
What is on the early exhausted funds tracker or EEFT
If you are having issues with your computer who should you reach out to?
What is your supervisor who will inform IT
If you enter SF and see an orange box around the screen which SF are you in
What is prime
If a member is on advantage and they speak with 1 person who addresses all their needs what is that person called ?
What is a NAV or Navigator
If you verify Full name , DOB and Zip code for a member you have fully verified the member?
What is False
Zip code is fine for pharmacy but members need to verify full mailing address
Name the MFGR that if funds have reached $3800 we can approve payment
What is Abbvie
Who should you contact if you are out for an extended period of time and need assistance with short term disability?
What is HR or Supervisor than HR
If you see on the members details page, the description box NAV that stands for the Navigator what type of member is this?
What is Advantage
If on a members paid claim in CSP you see a deductible before and deductible after is $0 with a balance remaining what type of claim is this?
What is a straddle claim
If a member calls in with a 2023 DOS you should review claim and if payment is truly due verify with CQ and make payment?
What is False
SOSP is no longer processing 2023 DOS, this claim should be escalated to Brianna for Accredo to write off
If a drug is not on the EEFT or early exhausted funds tracker and we discover it is exhausting early who do we contact to have that drug added?
What is Jenna or Jacquie
What 2 forms of communication should be used when leaving for the day or calling in sick?
What is email WF and Calling sup line
Standard set up is 30% coinsurance but not recommended, If the member declines the plan may decide on a benefit verification
What is Target
When an advantage member is awaiting PAP approval but has a fill that we approve before complete what is this called?
What is a bridge fill
What is true
Please name the MFGR with this information listed on the calls vs data load- May reject with last claim if greater than remaining CPA funds
What is Takeda
If you are having issues with a coworker and you want to discuss with someone who should you reach out to?
What is supervisor or HR if needed
who will then review and advise if additional steps are needed