Where Do I Look?
I find the benefits center info, other insurance carriers (for vision & dental) info & if we handle premiums, I find that here too.
Toolkit
Member wants generic for moxifloxacin, how do I know which one would be the correct formulary
Then generic form (most times in all lowercase letters) would be the blue hyperlink
To initiate a DMR form for medical claims, what intent should you use?
Review medical claim history
Generate code for member to workout
Renew Active Code Generator
First things first on the call?
HIPAA verification, plan type, Employer Group
If I need to quote a member’s 2023 benefits, I may look here.
Sharepoint (EOC)
What should I do if the medication I am researching says “excluded”?
Check the Griff to see if there is a bonus drug list. If so, search the medication using the bonus drug list’s formulary. If not, inform the member it is not a covered medication.
When would you use “balanced billing” during a claim review? What should you do?
Anytime a member is being billed for more than their responsibility.
Ensure it’s a bill, inquire payment status of member then contact provider’s billing dept?
Coverage Determination
PAS
After member tells you the reason for call, what should you do?
Reiterate it back to ensure clarity and assure member you both will work through the matter together
If IBAAG is not accessible, I can quote member benefits from these places.
The Griff & Sharepoint (EOC)
When quoting cost share for a medication, what should you research first? Why?
The coverage stage because that would give insight on the pricing;
Deductible- must be met before plan kicks in
Initial Coverage- typical copay/ coinsuranve
Gap “Donut Hole”- 75/25 split per CMS (unless Gap Coverage is offered, check Griff)
Catastrophic- x for generic, x for all other medications (regardless of tiers)
What is a great way to understand what all was billed for a visit and why?
input CPT codes in Knowledge Library
Check member’s type of plan & prior authorization status and notes
ICUE
As you are working through the issue, member is venting about how this matter is a tedious process and it’s taking quite some time to figure out. What should you do?
File a verbal grievance
If a member calls to check on the status of a prior auth submission, I may look here.
On the summary tab, in the medical tile & select prior auth OR ICUE
If a medication needs to be used more frequent than what is allowed per formulary, what needs to happen for member to be potentially covered?
Coverage determination (with medical necessity)
if a member disagrees with their cost share due to the processing of a claim, what should advocate do?
File appeal and verbal grievance
Claim decoder, COB flag removal
Macros
When should you document “disconnected call”?
Every time a call is disconnected. Include if the callback attempt was successful or unsuccessful.
Member has submitted a DMR form and wants to know the status
ORS History
When would a member use a specialty pharmacy
For a compound medication
If the claim was denied and the decoder reads “criteria not met”, what should be done?
Contact the provider’s office to either resubmit the claim using correct billing code or have them submit appeal with supporting documentation for medical necessity
List of Member’s EOBs
Doc360
When should you schedule a commitment?
Only when advocate cannot reach necessary parties (provider, pharmacy, DME vendor) to resolve issue.