MAESTRO
WHAT INTENT IS USED TO EMAIL DMR FORMS FOR MEDICAL CLAIMS
SEND INFORMATIVE EMAIL
WHAT INFORMATION SHOULD YOU ADD TO YOUR TRANSPORTATION GRIEVANCES?
THE TRANSPORTATION EMAIL
CAN AN AUTHORIZED REPRESENTATIVE FILE AN MIOD/CD FOR A MEMBER?
YES, WITH VERBAL PERMISSION FROM THE MEMBER. NOTATE CORRECTLY
ARE YOU ABLE TO VIEW PRIOR YEAR BENEFITS WITHIN THE REVIEW BENEFITS TAB?
YES
WHERE WOULD YOU LOCATE IF A CLAIM WAS DENIED UNDER THE REVIEW CLAIMS INTENT?
SERVICE LINE DETAIL
WHERE WOULD YOU FIND MEMBERS RX GROUP INFORMATION?
PLAN TAB
WHERE DO YOU GO TO MAKE CORRECTIONS/OR CHANGE A GRIEVANCE YOU HAVE SUBMITTED??
HISTORY AND ATTACHMENTS/ADD NOTE
CAN YOU PROVIDE THE MEMBERS MBI (MEDICARE BENEFICIARY ID) TO ANYONE OTHER THEN THE MEMBER?
NO, UNLESS OTHERWISE INDICATED IN THE INDIVIDUAL CALLER TYPE JOB AID
WHATS THE DIFFERENCE BETWEEN A GATEKEEPER PLAN AND AN OPEN ACCESS PLAN?
Gatekeeper plans require a referral for specialists.
WHERE WOUD YOU FIND A MEMBERS RESPONSIBILITY ON A CLAIM IN REVIEW MEDICAL CLAIMS INTENT
FINANCIAL DETAIL
WHAT INTENT WOULD YOU ACCESS TO VERIFY A MEDICATION WAS ELIGIBLE ON A MEMBERS PLAN?
FORMULARY LOOK-UP
WHATS THE DIFFERENCE BETWEEN A VERBAL GRIEVANCE AND A QUALITY OF CARE GRIEVANCE?
WHAT INFORMATION MUST YOU OBTAIN TO AUTHENTICATE A CALL FOR HIPPA PURPOSES?
The member needs to state their:
Obtain the following from the third-party caller:
HOW DOES THE OUT OF POCKET MAXIMUM WORK?
If the out-of-pocket maximum has been met and the benefit applies, the member would not have a cost sharing amount for covered services. Benefits which do not apply to the out-of-pocket maximum will still require a cost sharing amount.
THE PRACTICE OF BILLING A PATIENT FOR CHARGES NOT PAID BY HIS/HER INSURANCE PLAN BECAUSE THE CHARGES ARE IN EXCESS OF COVERED AMOUNTS/CUSTOMARY RATES IS CALLED?
BALANCE BILLING
WHAT INTENT WOULD YOU ACCESS TO DETERMINE THE MEMBERS BENEFIT STAGE FOR THEIR MEDICATIONS
COVERAGE STAGE
What needs to be included in every grievance submitted either verbal or QOC?
Who - who is the caller (member, AR, POA). Names of all the relevant people in the documentation (doctor's name, office staff, the member or someone on behalf of the member, etc.)
What - What is the complaint. Main points from the caller as to what happened
When - When did the event take place (date) if possible, the time of the issue
Where - Where did the situation occur. Location of the issue (some doctors have several offices or a facility)
Why - Why the caller is expressing dissatisfaction
How - How did you resolve the issue. What steps did you take?
Appeal address given to the caller (if applicable)
WHAT INFORMATION CAN BE DISCUSSED WITH AN AR OR THIRD PARTY.
The following information types can be discussed, unless limited by the member. Refer to HIPAA - Definitions for more details on information types.
WHAT ARE THE 4 LOOKUP TOOLS OFFERED IN THE REVIEW BENEFITS TAB TO ASSIST YOU?
WELLNESS GRID
PRIOR AUTH LIST
IBAAG
EOC/ANOC
WHERE CAN YOU LOCATE A DENIAL LETTER?
DOC360, Billing Intent, Claims Intent and the Pharmacy Intent
WHERE WOULD YOU FIND HOW/WHEN A MEMBER WAS ENROLLED WITH UHC?
THE APPLICATION TAB
WHEN ARE MEMBERS SENT LETTERS ON THEIR GRIEVANCES THEY SUBMIT?
MEMBERS ARE SENT LETTERS WHEN THEY SUBMIT A QOC INFORMING THEM THEY A QOC GRIEVANCE WS SUBMITTED ON ON THEIR BEHALF AND IT IS BEING INVESTIGATED. A&G LETTERS WHICH HAVE BEEN SENT TO MEMBERS ARE VIEW-ABLE IJN DOC360
WHAT DOES HIPPA STAND FOR?
Health Insurance Portability and Accountability Act.
NAME 8 BENEFITS OFFERED IN THE WELLNESS GRID
VIRTUAL VISIT
ROUTINE VISIONROUTIE TRANSPORTATION
ROUTIE CHIRO
PERS
NURSELINE
NATUROPATHY
MEALS
HEARING
HEALTHY FOOD BENEFIT
FITNESS
DEBIT CARD
DENTAL
CATALOG
ACCUPUNCTURE
HOW CAN YOU DETERMINE THE EXPECTED COST FOR A MEDICATION, VERIFY IF A ADMINISTRATIVE OVERRIDE IS NEEDED OR ACTIVE OR ENSURE A PHARMACY PROCESSING ACCURACY AND REAASURANCE FOR THE MEMBER?
RUN A PHARMACY TRIAL CLAIM