Systems
What system do you use when a member calls in regarding their medical benefits?
Debut
When a member calls in unauthenticated what 3 pieces of information do you need to obtain from caller?
Member ID, DOB, zipcode
What would your classification and intent be in quickstart if the member called in to order a new ID card?
Fullfillment:ID card/access card request
What benefit would you quote if the member was calling in to check their member responsibility for an ultrasound?
basic radiology
Why did this claim deny?
048- NDC NOT COVERED- NON FORMULARY DRUG
What system do you use when a member calls in regarding a letter/text/call they received?
RTI/EMME
What tab in CRM would you check to see if caller has consent or POA to speak on behalf of the member?
HIPAA Forms tab on Person Account page
What would your classification and intent be in quickstart if the member was calling in to get their benefit for their healthy options allowance?
Humana Spending account card: Healthy options
Which Tool would you use to verify provider contracts and network information if it is not found in Find Care Medical?
Provider at a Glance (PAAG)
What tool do you use to initate a prior authorization for member?
Promptpa
What system do you use to when a member is calling in to make a premium payment?
E-billing
If caller comes in unauthenticated and is not the member, what information can you give without authenticating them?
General information
What would your classification and intent be in QuickStart if the member is calling in to find out their copay for an MRI?
benefits/verification
What is a smartsummary (in your own words)?
A Smart Summary is a monthly, personalized statement that helps Medicare members review their health care claims, costs, and benefits information in one place
What is the ONLY exception that would result in Humana covering lost or damaged medications?
Natural Disaster/disaster exception
What system do you use when a member calls in to find a new provider
Find Care Medical
if member does not know their member ID, what other numbers can you use to authenticate them?
Medicare ID
Social Security Number (DO NOT OUT RIGHT ASK FOR THIS)
What would your classification and intent be in quickstart if the member was calling into update their primary care physician?
PCP change/ PCP Change made
How much time does a member have to file a verbal or written grievance?
60 days
What is the True out of Pocket amount for 2026?
$2100
Describe the difference between RxNova and RxConnect Pro
RxNova is used to research pharmacy claims and RxConnect Pro is used to find the benefits on specific medications
What mentor document would you use if you had questions about authentication?
HIPAA Overview
What would your classification and intent be in quickstart if the member was calling in to check if a medication was covered ?
Rx/ Benefits & Copayments
What is a Late Enrollment Penalty?
It is a premium penalty for not having Part D coverage for 63 days or more.
Which RxNova Call Connect tab would show you the status of a check issued to a member who submitted a paper claim for Direct Reimbursment (DMR) ?
Reimbursement