Where Do I Look?
It’s In The Formulary
Claims
Systems
Call Handling
100

I find the benefits center info, other insurance carriers (for vision & dental) info & if we handle premiums, I find that here too.

Toolkit

100

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

100

To initiate a DMR form for medical claims, what intent should you use?

Review medical claim history

100

Generate code for member to workout

Renew Active Code Generator

100

First things first on the call?

HIPAA verification, plan type, Employer Group

200

If I need to quote a member’s 2023 benefits, I may look here. 

Sharepoint (EOC)

200

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.

200

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?

200

Coverage Determination

PAS

200

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

300

If IBAAG is not accessible, I can quote member benefits from these places. 

The Griff & Sharepoint (EOC)

300

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)

300

What is a great way to understand what all was billed for a visit and why?

input CPT codes in Knowledge Library 

300

Check member’s type of plan & prior authorization status and notes

ICUE

300

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 

400

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

400

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)

400

if a member disagrees with their cost share due to the processing of a claim, what should advocate do?

File appeal and verbal grievance 

400

Claim decoder, COB flag removal

Macros

400

When should you document “disconnected call”?

Every time a call is disconnected. Include if the callback attempt was successful or unsuccessful.

500

Member has submitted a DMR form and wants to know the status 

ORS History

500

When would a member use a specialty pharmacy 

For a compound medication 

500

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 

500

List of Member’s EOBs

Doc360

500

When should you schedule a commitment?

Only when advocate cannot reach necessary parties (provider, pharmacy, DME vendor) to resolve issue.