Facets
You can only look up a member by family link in facets
True or False
(hint: discussed this while Es was out)
FALSE
You can look up member by member ID as well as family link.
What system do we use to update PCPs?
FACETS
Some members may not populate by their subscriber ID?
True or False?
TRUE
(Extra 100 bonus points if you say what they may be pulled by if it's not the sub ID)
What SOP do we use for Medicaid PCP changes?
Search and Assign Provider Intent (Medicaid)
KM1273654
If a Medicaid member wants to speak to an American Representative and no longer wants to speak with T1, would we take this call?
YES.
We take all calls where members are requesting an American Rep.
What tab do we use to see if member is active?
Eligibility tab
What system other than RX claims can be used to find RX prior auths?
PAS
Using NextGen ONLY
What is the start date of this members plan?
ID: 703002540
Member Name: AMAYA , ALEJANDRO
02/01/2025
This SOP can be used for Medicaid Claims Inquiries
FALSE, this SOP function is for M&R DSNP.
What Value Added Benefit do we offer for NY Medicaid members who are seeking the following:
Adult Day Care
NY Medicaid- Value Added benefits
KM1902815
We can assist members with cancelling commercial COBs.
True or False?
FALSE.
Members must contact their employer on their own to cancel their commercial plans.
Maestro is our source of truth.
True or False
FALSE
While we use maestro daily, we always cross reference and verify information in other systems to confirm our information.
We often use the "CARE ASSIGNMENT HISTORY"
tab in NextGen.
True or False?
FALSE
This is a tab we do NOT use.
T1 calls in because they need assistance locating an SOP that provides steps to reviewing a COB route that was previously completed.
What SOP would you provide?
COB (Medicaid) KM1266404
COB Macess Route Search
For A&G call handling, if a member threatens legal action what should we document?
Member called in because their claims are denying for alt insurance on file.
The member stated "I don't have any other insurance"
How would who's name the policy is in?
Either walk through steps verbally or share screen
VA Member wants to change their RX lock in, every time her medication is prescribed its out of stock at this location.
What sharepoint would we use?
T1 called in stating member's RX is denying, the pharmacy advised the members profile is showing the incorrect gender.
Member is showing as male for the prescription but should be female.
It was already confirmed by T1 the Medicaid state portal member is showing as a FEMALE. You researched RPA and confirmed member should be FEMALE as well.
Can we update this information?
YES.
This information can be updated in the member demographics area in NEXTGEN.
If an AZ member needs Liasion Services, what email can call center advocates message?
f the member needs Liaison Services, call center advocates can send an email to the Office of Individual and Family Affairs (OIFA).
Email: advocate.oifa@uhc.com
This common email phrase is used when you're trying to sound polite but you're annoyed that the person you are speaking with clearly did NOT read what you said.
"Per my last email"
We only notate in Facets when updating members PCP.
Yes or No.
NO.
We notate in Maestro.
Trick Question ;)
Using ICUE ONLY...
Are there any notations that indicate a P2P was completed for this authorization?
Share your screen to show the answer.
Member: RYAN PULLEN
ID: 123650893
Auth: A268779123 MERRICK CARE AND REHAB
Yes, notation from 03-25-2025 04:15:06
RequestNote Details: Peer to Peer was completed on this member.
Denial was upheld but LCD was changed to 3/27/25 with DC needed on 3/28/25.
Share your screen and show the steps to flipping the flag for this member:
Member ID: 133218184
Name: Stephen K. Blackmon
(If he hypothetically needed a flag flipped)
Share Screen
New Jersey Medicaid member called in to inquire about DMR, they stated "I don't feel like mailing in my reimbursement request and I was told by the previous representative that I can email this to a supervisor"
What SOP would we use to assist?
What would be tell the member?
DMR (Medicaid) - KM1221933
We would advise member per SOP ^
New Jersey state specific box: Members can request medical direct member reimbursement ONLY via mail to the claims address as shown on ID card.
This corporate phrase is often used to avoid saying the word "no" directly and means "we are probably not doing that"
"Lets Circle Back"