Additional Calls
When receiving a CMS Test Call, what are the correct Classification and Intent selections?
a) Other & Test Call
b) Misrouted Call & Transferred to Correct Skill
c) Benefits & Verification
Where will you find MRI benefit information in DEBUT?
a) Outpatient Advanced Imaging Services
b) Outpatient Radiology
c) Outpatient Diagnostic Procedures
Which of the following is NOT an example of Durable Medical Equipment (DME)?
a) Wheelchair
b) Catheter
c) CPAP Machine
Which tool is used to verify Provider contracts and network information?
a) Provider at a Glance (PAAG)
b) Customer Relationship Management (CRM) System
A new ID card is automatically issued anytime a PCP is updated for members with which plan type?
a) HMO
b) PPO
c) PFFS
A medical preauthorization pending status for a non-urgent/non-expedited appeal should not exceed what timeframe?
c) As soon as possible but no later than 14 days from date of request
d) 30 days from date of request
How do you schedule time to place an outbound return call to a member when needed?
a) Set a time with member and make a note for yourself to call them back
b) Create a CRM Notification Task and route it based on Mentor’s guidance
c) Send an email to your supervisor and leave the case open until you hear back from them
Which of the following is NOT considered a Medicare covered dental service?
a) Fracture of the jaw or facial bones
b) Routine extractions
d) Setting fractures of the jaw
When updating a Primary Care Physician (PCP), and the member has a specific provider in mind, what do you do
a) Check the provider’s availability in the Find Care tool.
b) Check the provider’s availability by performing a Physician Search within the PCP Change Template.
c) Contact the provider’s office to determine their availability.
When a hospital is in-network (INN) for a member’s plan, what does this mean for the physicians that practice at that location?
a) All physicians are in-network (INN) as well
c) A separate physician search must occur to confirm
If a member is not satisfied with the denial of their medical preauthorization, what option (if any) do they have?
a) Ask doctor to submit same request again
b) File a Grievance
c) Request an Appeal
Call from a plan type: MCD.
What is your next step after authenticating the caller?
a) Offer the member the number to the Medicaid department and Consult transfer
b) Take care of what you're able to, then transfer to Medicaid department
How are calls involving organ transplant benefits (i.e. heart, kidney, lung etc.) handled?
a) Quote surgery copays via DEBUT.
b) Advise callers prior authorization is required and offer requirements for inpatient surgery.
c) Warm transfer callers to the Transplant Management Team.
Where will you access Find Care to answer Provider-related questions when the member has a plan with a future effective date?
How do you handle calls for members seeking to locate a counselor/therapist to receive mental health counseling for depression and anxiety?
b) Locate the related benefits such as inpatient mental health therapy
c) Transfer the caller to the appropriate Behavioral Health vendor based on their plan's marke
Which of the following statements is true with regard to medical supplies?
a) Supplies are able to withstand repeated use
b) Supplies can only be purchased to treat a medical condition
c) Supplies require a prescription or certificate of medical necessity
d) Supplies are disposable
A member is due for a routine mammogram, but her doctor has recommended that she get a more advanced 3D scan.
How would you quote this benefit?
a) Quote both Preventive Breast Cancer Screening and Diagnostic Mammography via DEBUT
b) Quote only Diagnostic Mammography via DEBUT
c) Advise the member an authorization is required for this more advanced testing
How do you handle calls regarding members asking about Gastric Bypass surgery for weight loss?
c) Advise that another area will assist them and transfer the caller to CIT to get the authorization initiated
d) Advise that another area will assist them and transfer the caller to a dedicated associate for bariatric calls
A member is struggling with finding a Cardiologist that is in network. The member states they are having trouble with Humana.com and find it confusing.
a) Offer to mail a Provider Directory to their mailing address on file.
b) Assist the member by using Find Care and provide contact information as requested.
c) Show empathy and offer to guide the member through the Find Care tool to help them understand how it works.
A member is reporting an out-of-state address change effective immediately but also wants benefit information for a surgery that will occur in a few months.
a) Advise them we’ll wait to update their address until after the surgery as their plan will change and it could interfere with the planned surgery.
b) Update the address and connect them to sales for a plan update in their new state at which time, we can provide benefit information under their new plan.
Of the plans listed, which is the only Humana Medicare plan that may require a referral?
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When required, whose responsibility is it to ensure a preauthorization or referral is on file?
a) HMO
c) The Member
b) PFFS
d) a & c
e) The Provider
The definition of a referral authorization is:
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The definition of a preauthorization is:
a) Preauthorization is the process of obtaining certification from the health plan for inpatient or outpatient services.
b) Referral is the process of obtaining certification or preauthorization from the health plan for inpatient or outpatient medical services
c)Preauthorization is a requirement of a PCP to notify Humana when a member is being referred to a specialist.
d) Referral is the process of obtaining a referral from the health plan for outpatient services provided outside the PCP`s office or network.
e) a & d
f) b & c
Which part of Medicare is a glucose meter covered under?
a) The member's Part D Prescription Drug plan
b) The member's Part B DME Medical benefit
Which of these Part B plans require accessing the referral guidance tool to verify if a referral is required?
d) MER (HMO) and MRO (HMO-POS)
b) MEP (PPO) and MER (HMO)
c) MRO (HMO-POS)
You determine that a preauthorization is required for a specific service and is managed by Humana CIT, how do you handle the call if the member wants to initiate the preauthorization?
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What resource do you use when determining whether a preauthorization is required for a service?
a) Consult transfer the caller to CIT to initiate the authorization.
b) Advise the caller that their provider must submit the authorization.
c) Humana Customer Care Preauthorization and Notification List Tool
d) Referral Guidance Tool
e) a & c