Eligibility
What stands for MA and MAPD
MA: Medicare Advantage
MAPD: Medicare Advantage with Prescription Drug coverage.
In CRM we have 2 tools we can use to view the communications sent to the members, what are the names?
EMME and RTI
What is the name of the CI screen where we can find the name of the Primary Care Provider of a member?
PAMG
What is the name of the tool we use to quote benefits?
Debut
Difference between Referrals and Authorizations
Referrals: for HMO plans and for consultation services.
Authorizations: for any type of plan and for medical services such as procedures.
What is the effective date of Humana's policies?
The first of the month
Is the name of the monthly statements that Humana sends to their members
Smart Summary
What is the name of the CI screen where we create the task for a demographic change?
PATR
What is the name of the document/tool we cannot share with members neither via email nor mail?
Benefit Grid.
How many days does an authorization takes to be approved?
Standard: 7-14 days
Expediate: up to 72 hours (3 days)
Per HIPPA, what are the main elements we got to ask the caller in order to AUTHENTICATE the call?
Humana ID, Medicare ID or SSA
Name
Date of birth
Zip code
What stands for COB?
Coordination of Benefits.
What stands for OSA?
Out of Service Area.
What is the name of the Mentor we use to quote benefits?
Verification of Benefits (VOB) Medicare Overview.
What is the name of the tool where we verify if a member needs a referral?
Referral Guidance Tool
What stands for MRO - MAPD
Humana Gold Plus POS - Medicare Advantage with Prescription Drug coverage.
What is premium and LEP?
Premium: Monthly payment forward to the insurance carriers in exchange of monthly coverage for their medical services.
Late Enrollment Penalty: Penalty assessed by Original Medicare due to having a gap for more than 63 continuous days without Part D coverage once eligible at 65 years old.
What are the changes that we can make with previous CMS corroboration?
Name
Gender
Date of birth
Medicare ID
Social Security ID
Date of death
List the elements of the Benefits cycle
Identifying
Quoting
Verify the provider (PAR vs NON PAR)
Identify if a preauthorization is required
Identify if a referral is required
What is the name of the Mentor we follow for Medical Authorization calls?
Medical Preauthorization and Referrals overview Medicare and MMP
If the caller is not the member, what should we ask in order to AUTHENTICATE the call?
The member's information.
Agent or Broker: SAN ID or Agent ID.
Provider: NPI number and Name.
Name the automatic payment options for premium?
Credit/Debir card
Checking or Savings account
SSA deduction.
What is the name of the codes that we need to compare in PAAG before making a PCP change?
Super network codes
How many and what are the names of the therapies service that Humana covers?
Chemotherapy
Chiropractic services.
Radiation Therapy
Cardiac Therapy
Physical Therapy
Occupational Therapy
Speech Therapy
Audiology Therapy
How do we commonly refer to the Humana Customer Care Preauthorization and Notification List?
PAL list.