Show:
Member Inquires
System Navigation
QNXT Navigation
Grievances/Appeals
Systems
100

Member is calling in about Home Health Services

Who is Case Manager?

100

Finding the EOC in GPS

Plan Name/Health Policy Documents/View

100

 Steps when a member does not have their ID Number in QNXT

What is Last name, First name

100

When a member calls in upset about their Extra Benefits Card not working, we file a Grievance?  True or False?

What is True

100

Where would we go to look up members Chronic Condtions VCC Form?

What is Market Prominence

200

Member is calling because they lost their Extra Benefits Card

Who is OTCHS?

200

Finding a Specialist in GPS

What is the Menu Navigation/Find Care tabs?

200

The line of eligibility we use to ordering member materials for a Michigan HIDE member? Walk us through how to do this.......

What is Secondary Line of Eligibility?

200

Filing a Pre-Service Appeal for a C-SNP member? 

What is Creating a Service Request 

200

Where would we go to see who is a CSNP member's Case Manager?

What is Medcompass

300

877-476-3457


What is the CSNP Premium Payment phone number?

300

Finding the MBI

Policy Name/View Member Attributes/ Medicare ID

300

The line of eligibility we use to for ordering member materials for a Virginia HIDE member? Walk us through how to do this.......

What is Primary Line of Eligibility

300

What information is important when documenting a Grievance?

1. Complaint ( Grievance Complaint)

2. Dates of occurance

3. Partys involved

4.Requested Resolution

5.Name, Member ID and most inportant Time when Call was taken as well as member Address/Phone Number


6.

300

What System would we use for FIDE, HIDE members to look up CPT Codes?

What is ProPat

400

Imaging Prior Authorization status

Who is Evicore?

400

POA or PHI on File

What do you find in the Privacy Restrictions and Authorizations Information Tab

400

New Jersey member calls in for a PCP change- name lines of eligibility that need to be updated for the PCP change

What is Medicare-Primary and Medicaid-Secondary Lines of Eligibility

400

A memebrs MRI is denied becasue the plan determines it is not medically necessary. What process may the member use to challenge the decision?

What is an Appeal

400

What system would we use to look up CSNP member's CPT Codes?

What is Flash Code

500

Finding a Medication Tier

What is the Formulary

500

Name the KA  we would pull up if a call comes in "ringing out" and the proper way to answer that call

KA 3053-

  • “Hello, my name is <your name> calling from your health plan with your requested callback. Am I speaking to the <member, person who placed the request for callback>? May I have you name and id#?”
  • CSRs need to state the call recording disclaimer. The call is recorded, and the CSR should let the caller know. If they do not there will be no other warning for the caller.
  • It is very important to validate the call with normal HIPAA and Privacy procedures to ensure we are speaking with the authorized caller. Also, see the new CTI Pop above.
500

Where in Assist Edge QNXT  would you go to look up CPT Codes

What is ProPat

500

A member states that their Specialist keeps arriving late to appointments, what type of issue is this?

What is a Grievance.

500

Amy's dogs name?

Who is Shianna (Shi)