ENNE
A concerned member who is locked out of their account is trying to reorder their prescriptions. What is the correct guidance to offer in this situation?
a) Advise the caller you are going to unlock their account. Utilize CSR Password Reset to unlock their account.
b) Advise the caller to login and click on “Forgot Password.” Utilize Mentor document: Member Username and Password Issues.
c) Advise the caller you will need to escalate this incident to security. Utilize Mentor document: Escalate an Incident to Security.
a) Advise the caller you are going to unlock their account. Utilize CSR Password Reset to unlock their account.
Humana does not cover replacement of lost, stolen, or damaged medications. However, you (the advocate) can offer members some helpful suggestions. Which one of the following is NOT an appropriate suggestion in this case?
a) Contact their doctor or manufacturer to see if they have/offer free samples
b) Check if the pharmacy can “loan” a small amount from the next fill
c) Seek reimbursement through their home/renter’s insurance policy
d) Call “211”, a nationwide Help Referral Service for local resources available
e) Advise the member to file an appeal with the insurance company for a one-time exception.
e) Advise the member to file an appeal with the insurance company for a one-time exception.
According to the Medicare Immunization Coverage Reference guideline, how is the Pneumococcal vaccine covered?
a) Under Medicare Part B
b) Under Medicare Part D
c) HCPR must review to determine B vs. D coverage
a) Under Medicare Part B
) What is the only exception that would result in Humana covering a lost or damaged medication?
a) An isolated personal crisis exception.
b) A disaster exception.
c) An exception granted by the pharmacy due to prior authorization delay.
d) A one-time override request submitted by the member’s doctor
b) A disaster exception.
When addressing access to care issues (where members are unable to obtain their prescriptions when they need them), you must always confirm the member has enough medication to last how long?
a) 12 hours
b) 24 hours
c) 36
d) 48 hour
d) 48 hours
A PDP member is traveling across the U.S. to visit family and friends. Can they get their prescriptions filled in any state?
a) Yes, they can use any Humana pharmacy or get a vacation supply before they leave if they have not exhausted their limit.
b) Yes, but they’ll need to use CenterWell Pharmacy Mail Order for a 90-day supply of the prescription.
c) No, if traveling, they will be outside of their plan’s service area
a) Yes, they can use any Humana pharmacy or get a vacation supply before they leave if they have not exhausted their limit.
Members can choose to enroll in which Humana stand-alone prescription drug plans?
a) Value, Basic, or Premier
b) Preferred, Custom, or Elite
c) Enhanced, Standard, or Basic
a) Value, Basic, or Premier
Where in RxNova Call Connect is a member’s Low Income Subsidy (LIS) status located?
a) Benefits & Eligibility Deductible & Accumulators panel
b) Benefits & Eligibility Part D panel c) Benefits & Eligibility Dual Coverage panel
b) Benefits & Eligibility Part D panel
Where in CRM is a member’s Low Income Subsidy (LIS) status located?
a) Person Account page – Communication panel
b) Person Account page – Policies section
c) Plan Member page - Eligibility Information section
d) Plan Member page – Authorization/Referral Summary link
c) Plan Member page - Eligibility Information section
According to the Extra Help/LIS Comparison guideline, if a member’s LIS status shows 1001, what subsidy level is this?
a) Subsidy 1
b) Subsidy 3 and 4
c) Subsidy 7
d) The member does not have LIS
b) Subsidy 3 and 4
When verifying prescription drug (Part D) benefits, where will you confirm if the member reached or is nearing their initial stage?
a) Pharmacy Finder
b) CRM
c) RxNova Call Connect
c) RxNova Call Connect
The Member ID link from this RxNova Call Connect button is launched if needing to review a member’s pharmacy accumulations from the previous plan year.
a) Claim
b) Reimbursement
c) Benefits/Eligibility
c) Benefits/Eligibility
When verifying prescription drug (part D) benefits in RxConnect, how can you tell if a medication is not covered?
a) There are no Drug alternatives available.
b) “Not Covered” appears in the Coverage column.
c) The best deal indicator is not visible.
b) “Not Covered” appears in the Coverage column.
When viewing drug pricing results in RxConnect, what indicator represents the best deal for our members?
a) Lowest cost in the Member pays column
b) Lowest cost in the Total cost column
c) Amount corresponding to the green dollar sign
c) Amount corresponding to the green dollar sign
When verifying prescription drug (part D) benefits in RxConnect, how will you know if a medication requires prior authorization approval from HCPR?
a) “Prior Authorization”, “B vs D Determination”, or “Step Therapy” appears under the Coverage column
b) “Quantity Limits” appears in the Coverage column
c) When the medication is Tier 4 or higher
a) “Prior Authorization”, “B vs D Determination”, or “Step Therapy” appears under the Coverage column
A member expresses concern over the high copay cost of their prescription that their PCP states is the only effective medication for them. What is the best course of action?
a) Show empathy and advise them this estimate is accurate based on their current plan.
b) Advise the member they can request a tier exception and warm transfer them to HCPR.
c) Provide cost saving alternatives they can discuss with their doctor.
b) Advise the member they can request a tier exception and warm transfer them to HCPR.
When researching a denied drug claim in RxNova Call Connect, you find error code “082” listed under the Errors & Messages panel, what does this mean?
a) The medication is a CMS excluded drug.
b) The member is attempting to get an early refill.
c) Pre-authorization is required through HCPR.
c) Pre-authorization is required through HCPR.
If, while researching a different denied drug claim, you notice error code “221” is listed in the Errors & Messages panel, what does this mean?
a) The medication is for a drug covered under Part B only.
b) This is a duplicate charge for a claim previously processed.
c) The medication is covered, this is an informational error only.
a) The medication is for a drug covered under Part B only.
When confirming the amount (if any) a member owes on a drug claim, which dollar amount in RxNova Call Connect represents the member’s responsibility?
a) Plan Paid amount
b) Patient Paid amount
c) Sub Ingr Cost amount
b) Patient Paid amount
Which RxNova Call Connect option provides the status of check issued to members who submit a paper claim for Direct Member Reimbursement (DMR)?
a) Reimbursement
b) Formulary
c) Pharmacy
a) Reimbursement
How can you tell when a drug claim requiring correction was adjusted and reprocessed in RxNova Desktop?
a) A date is visible in the Adjustment date field.
b) The claim source will always show “DMR Long”.
c) The Plan paid amount will show a dollar amount.
a) A date is visible in the Adjustment date field.
The status of a prior authorization for a prescription drug can be found where in CRM?
a) Auth/Referral Summary tab under Pharmacy Authorization tab b) Contact Handling Alerts section c) Policy Member page under the Details tab
a) Auth/Referral Summary tab under Pharmacy Authorization tab
If the indicator under the RxNova Call Connect Dual Coverage panel shows “S”, what does this mean? a) The member does not have other insurance coverage besides Humana.
b) The member has other insurance (OI) – Humana is secondary.
c) The member has other insurance (OI) – Humana is primary.
b) The member has other insurance (OI) – Humana is secondary.
Mail Order demographic Information edited under the Demographics section is limited to ____________.
a) Primary phone numbers and email addresses
b) Alternate and Mobile phone numbers only
c) Contact numbers and email addresses d) Email addresses only
c) Contact numbers and email addresses
26)What information do you relay to the caller regarding ordered medication?
a) Type of Rx, Quantity, Next Fill Date, and Day Supply
b) Name, Dosage, Quantity, Day Supply, Next Fill Date and Remaining Refills
c) Name, Dosage, Quantity, and Day Supply
d) Type of Rx, Name, Dosage, and Next Fill Date
b) Name, Dosage, Quantity, Day Supply, Next Fill Date and Remaining Refills