HIPAA
What should be Authenticated when a member calls?
First and last name, DOB, and One of the following: Member ID/Medicare ID/Complete address.
Through this program, health care practitioners make in-home clinical visits (or virtual visits) with members to evaluate their health conditions. These visits are meant to support the care the member receives from their primary care provider.
House Call
What is the Index for Job Aid For UAW TRUST Index called?
What is UAW Trust - Index
Member calls to see if they are to pay a bill. How do you proceed in maestro?
Review Medical Claim History. COST Share - enter info (General Billing claim -post on wrap up) GET BOTH ANSWERS
True or False, An advocate must check with their FWA gatekeeper before submitting a Fraud Tip.
True
If the caller is unable or unwilling to verify caller what is the correct job aid?
HIPAA - Unable or Refusal to Verify
This visit is essential to ensuring our members lead the healthiest possible lives. This visit is provided at a $0 copay. After visit, completed member is able to earn a reward.
Annual Wellness Visit
How do you handle a OTC call for a member?
Non-Medical Benefits For questions about additional benefits not covered by UHC, warm transfer the caller to Retiree Health Care Connect (RHCC) at 866-637-7555 or provide the email to RHCC: uawtrust@rhac.com.
What does A Claim Denied for Limited Service mean?
The benefit allotted during the benefit year has been used or limited preventative services, capped visits, and/or dollar limits. Job Aid Benefit Inquiries - Limited Services
True or False, An Advocate should go ahead and submit a fraud tip when they feel without a doubt it is fraud
False! Advocates now must reach out to leadership just to be sure, in order to prevent waste
What is considered and Emergency situation?
An emergency situation occurs when a member is hospitalized, temporarily incapacitated, or unavailable due to a health issue.
Advise the caller: We can assist you today, given the emergency situation. However, if you will continue to need ongoing information, please send the documentation to us as soon as possible.
This help with reducing the need for members to contact the plan by analyzing many forms of data to determine the probable reasons why they are calling or reasons they might reach out in the future.
Potential Repeat Caller
Can members get a Covid-19 test kit from the Pharmacy?
Over the Counter Test kit benefit is no longer available. The benefit ended on December 31,2023.
How are Self Admin Drug charges are handled?
SAD drugs cannot be received in an outpatient or emergency department setting on a regular basis. Since most hospital pharmacies don't participate in Medicare Part D, the member may need to pay up front and out-of-pocket for these drugs and submit the claim for a refund. DMR Request - New Form tab
True or False, The Gatekeeper review prior to form submission will reduce cost on wasted efforts and resources
True
Who Can file A Grievance?
Active Member (or was active at the time of the VG)
Is offered to educate and refer member to complete medication review.
Comprehensive Medication Review
How many Orthopedic Shoes can UAW members get?
Member can get 2 ADDITIONAL DIABETIC SHOES from the standard Medicare benefit. IF they are diabetic only. DME Vendor Website Look Up - Index
Member gets a bill from the provider prior to a claim being processed by UnitedHealthcare
Early Billing - Claim has not been processed Claim Inquiries - Researching Balance Billing
True or False, An Advocate who believes they are being mislead should not report a member's potential Fraud grievance
False! We are considered note takers before we are investigators, so our personal input is unnecessary
What is the difference of Auth Rep and Caregiver?
Auth Rep - An individual who is granted, by the member, the right to discuss and/or receive the member's personal health information.
A caregiver is a person (family member, friend, neighbor, etc) Any individual providing assistance to a member, in any way and for any reason.
Auxiliary Persons - Types and Roles
Educate member and offer to schedule A1C blood sugar test
Diabetes Screening Kit Completion Reminder
How do we handle post-discharge for UAW member after a hospital stay?
Reach out to the Clinical Services Engagement Specialist. UHC Healthy at Home Job Aid
How is the Coinsurance amount calculated?
Coinsurance amount calculations are based on the Contracted fee or Medicare approved amounts for each service, not total claim amount. (Group Coinsurance/Copays are then applied)
True or False, The Gatekeeper review prior to form submission will increase our number of forms which are inappropriately submitted
False! The Gatekeeper process will decrease the number of forms incorrectly submitted