Common Audit Opportunities
If a referral is provided to a member what are the two places we must document in Pathway?
What is Communications, Referrals Made & SDoH link, add SDoH Referral?
What must we do on every call whether is a 3rd party, provider or the member?
What is advise the call is being recorded?
If we are calling the Authorized Representative on a quarterly outreach, what must we do first?
What is make sure the Authorized Representative is still listed with Member Services or validated in I-CUE?
What can we use to check member’s plan benefits?
What PHI counts as HIPAA authentication?
What is
First and Last name
Ful DOB
And ONE of the following: address (authentication may occur with number (including apartment number), street, and city/state OR number (including apartment number), street, and zip), or
Subscriber ID, or
Last 4 numbers of SN
If you have provided a member a specific specialist name and number, what option would you select in PW under "referrals made"?
What is General?
If the member initially declined a FTF visit but agrees to a quarterly telephonic contact, what is the proper sub status to select?
What is Unable to Engage?
What is the system used to obtain information such as Medicaid provider, Medicaid Level, Medicaid ID, and member demographics?
What is DMEVS?
What two outreaches do we confirm the name of the member's PCP as well as offer to schedule a follow up appointment with the PCP?
What is
the initial call and every 90 day follow up?
If you provide food, utility, and lawn maintenance resources, what do we select for the referrals made?
What is food, utility, and general?
If a facility/provider calls us back, what is the correct information to verify?
What is
-the name and address of the provider/facility
- authenticate ALL 3 of the HIPAA elements as you would if they were the member?
What is the name of the website we are to use to assist the member to find an chiropractor or acupuncture to utilize their ROUTINE benefit?
What is MYOPTUMHEALTHPHYSICALHEALTH.COM?
How often is the SDoH due, as of 10/11/22 per the SDoH job aid?
What is every 6 months?
If a 3rd party tells us the member is not interested in the OAH program, what is the appropriate disposition to select for the "Outcome?'
What is DNC?
What are the 4 reasons for a case closure?
HINT: This is found in a specifc job aid
What is
-MEMBER DECEASED
-LOSS OF ELIGIBLITY
-OPT OUT
-HOSPICE MEMBER
What is the specific website we use to verify if a member is eligible to receive in home urgent medical care provided by Dispatch Health?
What are the 5 main things the CN says to the member before ending the call?
What is
1. provide/offer callback number & extension
2. provide/offer Nurse line and MS (on the back of the card)
3. ask for any questions from the member
4. summarize key details of call
5. let the member know the timeframe/date of the next call and next steps?
If a member is dissatisfied with Modivcare, who do send an email to and what must be included?
HINT: This is found in a specfic jpb aid
What is
-qualityassurance@modivcare.com and CC: christine_armijo@uhc.com
-Member’s name
-Member’s ID
-State abbreviation
-Date of birth
-Effective date
-Contract and PBP Numbers
-Date of Service Reason for complaint?
What are the 7 star gaps that do not require action from a CN?
-ABA/BMI
-ART
-CDCNEPH
-HRM
-FMC
-MRP
-PCR
What are the 4 requirements to report emotional/physical abuse and what is the timeframe?
What is
1. Submit to the Complaints & Compliments Issue Mgmt SP
2. Call the local abuse hotline
3. Document Safety Concerns as Outcome in PW
4. make sure to document the Ticket Number for future reference
SUBMIT WITHIN 24 HOURS OF RECEIPT OR IDENTIFICATION (WHENEVER POSSIBLE