SME QUIZ

If a Medicare CC member from Healthfirst needs a service from an ONN provider and this service cant be provided by a INN provider, what options does have the member in order to obtain this service?

• Member can request a change of insurance

• Member cannot have the service if its not provided by a INN provider

• Member can request HF a Single case agreement

• The member needs to find an INN doctor

If an Unauthorized caller is calling about her father that is hospitalized but she is not listed as the RP on the account, SA Josemaria offered the proxy form and advise her she should get this form within to 7 to 10 business days but unauthorized caller told SA that she needed this form in a fastest way because it is an emergency, what options can offer SA Josemaria to the unauth? MULTIPLE CHOICE QUESTION

• SA can send this form through e-mail (Member support - Document request)

• SA can advise unauthorized that she can get this form on Healthfirst web page

• SA can send this form through e-mail (Member support - Correspondence request)

• SA should advise member that this is the only way she can get this form

Member JOSE E TORRES called in because he needs a Home care aide that can take care of him all day and also he advise that he only wants ONE aide that can live with him because of his daily necessities, what should SA do?

• SA should advise member that the only way to have this service, is with a split shift between two aides

• SA should advise member that this can only happen if he make a single case agreement.

• SA should advise that this is not possible.

• SA should advise that he can have a live in nurse but he must have adequate space in his home to accommodate the aide, and the aide is ensured at least 5 hours of uninterrupted sleep

A member called very upset because he wanted to make a complaint against the last representative he spoke to because he treated him in a bad way and didn't wanted to help him. What should SA do?

• Report this complaint via e-mail to #[e-mail]

• Make a A&G case on SF > Type appeal, subtype quality of care.

• Make a A&G case on SF > Type appeal, subtype customer service and also escalate this complaint to #[e-mail]

• Make a A&G case on SF > Type appeal, subtype customer service.

What is an important thing to remind after a member called in because they received a notice of collections for a bill and the SA submit an ABC case on Salesforce?

• Advise the member to call the collection agency and provide permission to Healthfirst, so we can contact the collection agency and address the billing inquiry on their behalf

• Advise the member to wait within 30 to 60 days so the resolution of this escalated case.

• Advise the member that this collection notice must be managed by the provider and not by healthfirst.

• Advise the member that in this kind of cases the MET resolution department needs at least 60 days within the call and it might result in a not covered bill because the member did not received the claims inquiry letter.

Effective 10/01 the $9 premium for CHP plan will be deleted

• True

• False

What does it mean the overturn indicator on ONBASE after we look up the resolution of an A&G case with the Hyland number?

• It is the initial adverse determination where the service will be partially approved

• Its is that the Resolution QUEUE from the A&G has not made a decision about the case yet

• It is the initial adverse determination where the service will be approved within 72 hours

When a person called in advising that it is the RP from a member, SA checked on system and there is a VALID PHI form, what case can SA submit in order to this information to appear on a SF case and make it easier next time for member/representative?

• Enrollment & Billing - update request

• Responsible party - RP VALID

• Documentation only - other

• Member support - Update request

When a person called in advising that this call is on behalf of a foster child member, and its not listed as the RP on SF, what should SA do in order to help this person?

• Verify the Responsible Party on BizTalk

• Access to the account as an unauthorized caller

• Ask the person that you will need to talk with the biological parent of the child

• Ask the agency name and the 3-Digit ID code

All Healthfirst plans have the part C, that means, all of them are Medicare Advantage, except for...?