Plans
A State of Tennessee member is calling to see if we would cover their Medicare Part A deductible, what would we advise to them?
We would tell them that their Medicare Part A deductible is covered by UMR.
Member ID: 39165981 is calling to get benefits for an Out of Network dermatologist, what would these benefits be?
There would be no coverage for an Out of Network dermatologist on this plan.
Member ID 41384324 is calling in to see if Optum enrolled her into their Infertility program? Was she enrolled? If so where would I find this information?
Optum did enroll her on 1/9/24 per the Referrals Tab in CPS.
Provider is calling to check the status of an appeal on a claim. Where would you go to check this?
Onbase >Reporting tab
Where would you look to find out if Hearing Tests are covered?
Routine Care > Hearing Sub Tab
A State of Tennessee member is calling in to update their mailing address, where should they be sent to?
They should be transferred to the State of Tennessee Benefits Office
A provider is calling in to update a members accident details. What would be your next step?
Inform providers that accident details updated by phone must
come from the member.
• Providers are able to submit medical records, emergency room
notes, etc. as proof that the services were not accident-related.
How often should you be populating your time on your time card?
Daily
A claim has denied with an ineligible code 947. What does this mean?
Charges denied. The service is excluded by your health plan.
Where would we find benefits for hypnosis?
Under covered/excluded tab
A State of Tennessee's family member is calling to report a members passing. Who would we transfer the family member to?
They should be transferred to the State of Tennessee Benefits Office. Since the plan is a retiree plan they do not have an HR department.
MID: 41429932 - Member is calling to see if pharmacy expenses are included with their medical deductible, what should we advise?
Yes this plans deductible does include the pharmacy deductible (Per the schedule of benefits tab)
What are the Fast Four Steps?
Recognize The Issue, Own It, Ask Permission, Ask Questions.
A providers claim is in review with SIU. Are we allowed to mention this to them?
Never indicate that the file is, or has been, reviewed by SIU.
Never mentioned the word fraud.
Do not transfer calls to the SIU Department for handling. These calls will be handled by the CFR. Please always refer to your supervisor/lead for assistance, if necessary.
Member is calling to see if they are covered for skilled nursing. Where would we check for benefits?
In HPDB under Extended care
A provider is calling in for a County of Westchester member wanting to know if the newborn deductible is waived for the first five days of the initial newborn stay, what would we tell them? (767000413268 BPN 001)
Yes, the deductible is waived for the first five days (Per the Pregnancy Tab)
Member ID 40830809 a provider is calling to start a prior authorization on a MRI. Who handle Prior auths for this plan?
What is one website we should be checking daily?
My Metrics
Where would you go to see the status of an appeal for a claim?
Onbase>Reporting
Health Plan Data Base
A County of Westchester member is calling to see if warning devices are covered, what would we tell them about their coverage for warning devices? (767000413268 BPN 001)
Per the covered/excluded services tab they are excluded by the County of Westchester plan.
MID: Y19458273 - Member is calling in to see what their urgent care benefits are for an in-network urgent care facility. What would we advise?
This is a trick question - All Member calls for this plan is handled by the IBEW Local Fund's Office.
How do you know if an employee is on a Cobra Plan?
The EE status will be 04
The Work status will be 21,22,32,54,or 55.
Mark is calling UMR to update his daughter's other insurance. Her insurance is Medicaid. Which plan will be the primary insurance?
UMR, we do not coordinate benefits with Medicaid.
Member is calling to see if their insulin is covered under their medical plan. Where would you check for this?
Drugs/specialty tab