Medicare Basics
What does LEP stand for and what is it?
A penalty imposed by CMS for not having a Part D coverage for 63 days or more.
When are member premiums due?
The 1st of every month.
What resource is used to determine when an authorization is required for a medical service?
Humana Customer Care Preauthorization and Notification List.
What are the types of PDP Plans that we work with?
* Basic
* Walmart Value
* Premier
OSA stands for Outside of service area. Proceed to make updates and transfer caller to DMS.
How long will it take for demographic changes to reflect in CRM and what is the name of the document that shows this information?
It could take 24-48 hours and the document is called Demographic Changes for medicare Overview.
A member calls on January 20th to report they permanently moved t California earlier that week. When will their plan terminate?
January 31st.
What is the correct way to handle calls regarding Gastric Bypass weight loss surgery.
Transfer the call to the Bariatric Department.
What does the Error code 023 stand? Also give an example of what you would say to the member?
Duplicate Claim: A claim was already processed.
How long does it take for mail checks to show up on our system?
7-10 business days.
How many steps are in the call flow and what are those?
There are 10 steps for the medicare call flow. All listed on the mentor document
What is the approval process for outpatient services provided by someone outside the members PCP office or Network?
A Referral
What is extra help and how much is a member paying for a preferred multisource drug on level: 0754?
Extra help is a federal program that helps reduce the out of pocket costs for medicare prescription drug coverage. $4.50 for generic or preferred multisource drug.
How long does a member have to submit their claim for reimbursement according to medicare?
CMS require that members are given 36 months from the date of prescription fill to submit their claim for reimbursement.
Does an ID card on a PPO policy shows the PCP on it? If PCP change is done on a PPO policy, will the new id card generate automatically or do we need to mail it manually for the pcp change to show up?
ID cards on PPO policies dont display PCP information. Id cards dont generate for a PCP change on PPO policies.
When are coupon books mailed for future plans?
Coupon books are mailed during november and december before the new plan year.
How do I know if a referral is needed? Provide the name of the document and the step or steps to follow.
We must check the mentor document: Referral guidance tool and filter it by state
What do we include on the 090 override authorization notes?
COB override
Humana user id
Drug name
What happens if a member is informed that their DMR is denied?
Member has the right to file an appeal
What are the preferred cost sharing retail pharmacies?
Albertsons
Costco
HEB
Centerwell Pharmacy
Publix
Sams Club
Walmart
When does the annual election period begin and end?
October 15th through December 7th
What is the difference between MA and MAPD plan?
MA: Medicare advantage plan - Medical benefits only
MAPD: Medicare advantage prescription drug plan, all benefits. (Medical and drugs)
What are the allowed occurrences for vacation overrides on Medicare and Medicaid members?
Medicare: twice a year
Medicaid: Once a year
What are the Humana Pillars?
1.Agent Helpful
2.Process Ease
3.Agent care
4. Agent Ease
5. Resolution