Claims
What information do we need to find the claim on file?
1. Name of the provider
2. Date of Service (DOS).
What is the timeframe for an expedited appeal?
72 hours
What does COB stand for?
Coordination of Benefits.
What is the processing time for a Billing Statement payment?
7-10 business days
What is an Override?
When member may need to refill their prescriptions sooner than expected, and the plan may allow an exception.
How can we determine if a claim is delegated?
1. If the claim number is too short.
2. If we see (**) at the end of the claim number.
3. PMG Info on the summary tab.
What is the timeframe for standard Part D - Appeals?
7 Calendar Days.
Where can I verify if the member has a COB Flag?
Summary tab
Will a member receive a monthly statement when using AUTOPAY (other's than bill statement)?
NO.
What do we need to show on the system to be able to process an Override?
The claim rejected for the specific medication for the same day of the call.
EX. If the member is calling 12/01, we need to have a claim REJECTED for 12/01. If we don't have one, we need to call the pharmacy.
What is balance billing?
Member being charged over their member responsibility on claim.
What are the main reasons to file an appeal?
1. Caller may present an issue in which the plan issued a denial (adverse decision) for a prior authorization or claim.
2. If the member believes that they are being held responsible for a Part C service or portion of a cost share amount that should be the health plan's responsibility.
What department should I call when the COB is for the part C of the plan? Can I bring the member with me?
1. Tier2 - RSS.
2. No, RSS are not supposed to speak with members.
What information do we need to process a EFT payment?
Account Holder Name, Bank Routing Number and Checking/Savings Account Number.
Who will determine if the Override can be processed?
OptumRx Pharmacy Help Desk and Transitional Override
What is the timeframe for claims processing?
30-60 calendar days.
What is the tab we use to verify appeals already submitted?
A&G tab / (Appeals and Grievances) tab
Should we provide the COBR department phone number to the member?
Do not provide this number to a member unless the member specifically requests it.
When is the SSA payment usually apply to the accounts?
Usually apply at the end or beginning of a month.
Mention 4 common reasons to request an Override?
1. Vacation.
2. Lost Medication.
3. Stolen or Damaged Medications.
4. Dose Change.
Can I verify if a provider is INN or ONN directly from a claim?
Yes, on the provider's information tab.
Who can submit an appeal?
Active member, Termed member, Legal representative, Providers, Any other caller with members permission.
If COBR department is closed, Can I remove the flag temporally?
Yes we can, using the Rx COB Flag Removal Macro.
Mention the MOP that we offer:
EFT, CC, Billing statement, SSA.
Do we have an specific task to process an Override?
NO.
We Call OptumRx Pharmacy Help Desk and Transitional Override for assistance. We can document on Claim History intent.