CAMS (Member ID: 341069504)
What is the advocacy that has the CAMS Quick Reference Guide?
Financial Advocacy (under Quick References)
Where can you find the group/BIN/PCN in ISET?
Pharmacy > RX Benefits - at the top
When does the auto-recall time frame start for claims?
Six-month window begins on the original claim's received date.
What is CAA?
The Consolidated Appropriations Act (CAA) was signed into law on 12/27/2020. Most provisions will be effective 1/1/2022. There are several provisions in the law, which are listed below:
What does PHI stand for?
Personal Health Information
What is the current balance?
$833.36
What is a Carve-Out plan?
A plan that we connect over to the team/vendor that handles the plan.
What EZcomm link should we send to a member that wants to submit a medical claim on myuhc.com?
Medical Claim Form
When do we have to send CAA letters?
This must be done even when provider status search results were sent via text or email. The letter is only required when member asks if a provider is INN. Letter is required to be sent whether the provider they are asking about is INN or OON.
What information do we have to document when a 3rd party caller is calling in?
First name, last initial and phone number.
What is the claim filing limit on the given policy?
120 days
What does reject code 75 mean?
Prior Authorization is needed.
How many days have to pass before we can initiate the balance bill process?
45 days passed since claim was last processed.
If the member calls in and asks for a list of dermatologists, do we have to send a CAA letter?
No, we only have to send them if the member is asking if a specific provider (doctor, facility, group, etc) is INN.
When do we have to ask if the call originator has permission to speak on the subject's behalf?
Anytime they are over the age of 13 or if they are a 3rd party caller for any subject.
Is the coordinated payment indicator check on the given policy?
Yes
How many vacation overrides can a member get in a year?
1 time per 365 days per prescription.
What do we do if the member calls in about a claim. The claim has an E8 remark code, and they are being balance billed but the member did not pay up front?
We would follow the balance bill process which leads to the balance billing naviguard process.
If the provider is not INN, are we required to send out the CAA letter?
Yes, we are required to send a letter whether the provider is INN or OON to confirm that we have verified the network status of the provider.
Who can request a POLC/COC Letter for the entire family?
Only the subscriber can request this for the entire family otherwise it can only be for the dependent who is on the phone with you currently.
Why is claim ID 791850947 denied?
No subscriber acct on dates of service
What is the process when a member can only take a medication that is a plan exclusion to have it covered under the benefits?
Advise member that the medication is typically not covered under the member's plan.
What is the suggested scripting to explain Medicare Estimation when the member is eligible for Medicare Part B but is not enrolled in it?
Medicare coverage is not automatic. You do need to enroll. You may want to get in touch with the Medicare Administration. They can give you enrollment information. They can also discuss when it would be a good time for you to enroll."
What are the two ways we can send the CAA letters?
Email or mail.
Can a subscriber request that a password be added for everyone on the policy if their children are 12 or older?
No, they can only request a password for themselves and minor dependents (11 years old or younger).