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Compliance and More!
Who said that?
Document or NOT to Document?
50 Million Systems
MadGab
100
This complaint type is about the care or service received from a medical provider and a layperson believes the incident may have resulted in, or has the potential to result in, a worsened medical condition....
What is Quality og Care Grievance. Reference: mySME Complaints Appeals and Grievances Glossary.
100
"Good Afternoon and thank you for calling UnitedHealthcare. My name is Amanda. Do I have the pleasure of speaking with Camille Cartwright today?” The above is an example of this type of greeting...
What is Positive Engagement HIPAA Verified Greeting. Reference: Greetings and Closings Positive Engagement Job Aid
100
-Employee name or initials. -Opinion regarding the issue or the caller. Manual documentation should be professional and reflect the facts of the issue. -Promised date or time for return calls; unless you personally can assure the call back and the documentation by that date and time. the above are examples of this type of documentation....
What is System Documentation: What NOT to Document
100
This system is used to view benefit information at a glance and comes in handy when using a particular screen in COSMOS...
What is IBAAG Reference: mySME IBAAG
100
Abe Odd Hulk Luck Oak
What is A bottle of Coke
200
The member must submit a timely request to the QIO (generally, no later than noon of the day following the receipt of the “Notice of Medicare Non-Coverage” (NOMNC), or by noon the day before the coverage ends) when filing this type of complaint....
What is Fast Track Appeal. Reference:mySME Complaints, Appeals, and Grievances Glossary
200
The Positive Engagement QA Team uses these five metrices for measuring a CCP's QA Performance...
What is Focus and Accountability, Positive Connection, Positive Vocalization, Proper Etiquette, Positive Scripting. Reference:mySME Positive Engagement Quality Definitions.
200
If a CCP receives a call from a prospective member asking to enroll in a PDP or MAPD plan, the call should be documented as this call type and transferred to Telesales.
What is a Misdirected Call. Reference:mySME System Documentation: Misdirected Call documentation
200
Used to locate approved, pending, or denied Organization Determinations Requests. It also has details of follow up care along with the physician facility and contact information...
What is ICUE. Reference: mySME ICUE-HSR Index, Organizations Determination Index.
200
Aid Are Crank Loud
What is A dark rain cloud
300
This must filed before a member can file an appeal...
What is Organization Determination. Reference:mySME Complaints, Appeals and Grievances Glossary
300
"It is nice to meet you Ms. Cartwright. I see you have called us within the last 30 days. Are you calling today regarding the same issue or is there a new question I can assist you with this afternoon?” The above is an example of this scripting if applicable to the call based on verbatim call flow...
What is Repeat Call Indicator. Reference:mySME Greetings and Closings Positive Engagement.
300
This function is set up to abbreviate important information related to an issue which provides consistency and fewer key strokes for the user within the Account Summary...
What is Auto Documentation Reference:mySME System Documentation> Auto Documentation
300
On this screen in this system CCP's can confirm True Balance billing exists when a claims amount is questioned by a member....
What is Screen TB208 and System: COSMOS. Reference: mySME COSMOS Quick Reference Guide.
300
Ape Arrows Unlce As His
What is A pair of sunglasses
400
The 2014 ANOC includes the statement “Current members can ask for an exception before next year and we will give you an answer within 72 hours after we receive your request (or your prescriber’s supporting statement). If we approve your request, you’ll be able to get your drug at the start of the new plan year” after filing this complaint type.
What is Request for Coverage Determination Prior to Effective Date and Mid-Year Change
400
“It was a pleasure helping you this Afternoon Ms. Cartwright. “Thank you for calling Customer Service, have a nice day.” Is an example of this call type.
What is Call Closing. Reference:mySME Greetings and Closings: Call Closing.
400
Verbal authorization received to speak to 3rd party: MIIM does not currently auto-doc that verbal authorization was received when speaking to a third party. CCPs need to document that they received verbal authorization from the member to speak to the third party in this section of MIIM if they did not already document it in the intent/interaction.
What is Wrap Up. Reference:mySME System Documentation>> WRap Up
400
I must gather these 3 pieces of information when completing a CSRF form in RxWeb that can only be located within this system...
What is Carrier, Group and Account information. What is Rxclaims. Reference: mySME Rxclaims Index and CSRF Form Jobaid
400
Fee Limber Raven Huff Toot Rye
What is Feel I'm brave enough to try
500
This group/department will make a decision regarding the member’s coverage determination using the timelines....
What is OptumRx. Reference:mySME Coverage Determination Turnaround Times
500
Utilizing the appropriate pleasantries throughout the call (e.g., Please, Thank You, "May I please have your ___" vs. "Give me your __"). Especially important to a caller for staying on a long hold. is an example of this Positive Engagement Metric....
What is Proper Etiquette. Reference: mySME Positive Engagement- Qa Definitions
500
The information for this documentation type can be accepted verbally from the physician or other provider; however, it is not acceptable from a member unless there is an exception stated in the applicable documentation...
What is Claim Missing Information. Reference:mySME System Documentation>>> Claim Missing Information.
500
When this option is not selected or checked, in this system, the CCP will be prompted to identify the caller and their relationship to the member...
What is The Caller is Member box. What is System MIIM. Reference:mySME MIIM Navigation>> Prospects and Members Verify Member/Non-Member
500
Pie Rate Softy Care Hip Been
What is Pirates of the Carribean