Authorizations
Quiz by Ashley Jones
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- Q1
An ICR receives a call from a POA on 08/14/21 who confirms the following:
"Hello. My mother accidently broke her dentures while she was moving boxes in our house. She placed a heavy box on top of them and they are completely damaged. I've spoken to my mother's dentist who informed me the dentures cannot be repaired whatsoever. I need her to be able to have dentures that she can use."
As the ICR, you proceed to conduct your research and confirm the following: Member is covered for dentures once every 5 years and a dental claim is on file reflecting she received dentures back in 2019 using her CarePlus benefits.
You educate the POA that the member’s dental benefits have been exhausted, however, can assist in submitting a benefit reinstatement authorization request for review and determination due to the circumstances.
Based on the above scenario, what STC(s) would you use to document the call interaction in regard to research and resolution?
C0262 and CP094
CP196 and C0169
C0262 and C0169
CP196 and C0212
300s - Q2
An ICR receives a call from a DOH on 08/30/21 who confirms the following:
"It's eleven fifty in the morning and I am hoping you can assist me. My sister has dialysis treatments scheduled three times a week as she was diagnosed with ESRD back in late July. She completed her first three dialysis treatments last week, however, I received a call from DaVita telling me that they did not have the approval on file for next week's visits. They did clarify everything is good to go for this week."
As the ICR, you proceed to conduct your research and confirm the following: The authorization on file has been exhausted since the member used it for last week's visits. Dr. Gomez (PCP) submitted an expedited authorization request for three months work of dialysis treatments which is in pending status on 08/30/21 at 9:36am.
Based on the above scenario, what STC would you use to document the call interaction in regard to research and resolution?
C0099
CP196
C0259
C0182
300s - Q3
An ICR receives a call from a member who confirms the following:
"Sweetheart, I am in so much pain and let me tell you why. When I went to my yearly checkup with my dentist, Dr. Lee told me that she's going to have to take out three of my back teeth. She said she is worried as it look like they may be infected and is causing sensitivity in my gums. Can you tell me if Dr. Lee sent the information so I can get teeth # 29, 30, and 31 out?"
As the ICR, you proceed to conduct your research and confirm the following: Member is covered for up to 2 simple or surgical extractions based on her benefit plan year.
You contacted Argus Dental to confirm if there is an authorization request on file and Tiffany advises that there is nothing in regard to extractions or any dental procedures. You contact the dental provider to coordinate the service, offer to submit a dental organization determination on the member’s behalf, and the member agrees to proceed with the organization determination process.
Based on the above scenario, what STC(s) would you use to document the call interaction in regard to research and resolution?
CP196 and C0169
C0262 and C0169
C0262 and CP094
CP196 and C0182
300s - Q4
An ICR receives a call from a member who is currently in hospice care and is receiving medical care at home for Chronic Obstructive Pulmonary Disease (COPD). The member states the following:
"I need to see a urologist for my prostate as I have an infection. My PCP gave me medications specifying because my laboratory results regarding my urine came back abnormal, it's best I am evaluated by a urinary specialist."
What action(s) should the ICR complete in order to fully assist the member with coordination of care and any education required?
Educate the member that their need for medical service is different from the reason that they are in hospice; therefore, his PCP needs to submit the authorization request for him to be able to see a neurologist. No organization determination may be submitted via Member Services.
Educate the member that while they are in hospice, Medicare covers their medical services, and he should contact Medicare for coordination assistance
Educate the member that their need for medical service is different from the reason that they are in hospice, contact the PCP to inquire on the request status and coordinate the service if applicable; initiate an expedited organization determination if needed
Educate the member that while they are in hospice, Medicare covers his medical services, and CarePlus only covers supplemental services; therefore, the hospice provider should contact Medicare for coordination assistance
300s - Q5
An ICR receives a call from a member who became effective with CarePlus on 07/01/21. The member states the following:
"I have a very big concern. My psychiatrist, Dr. John Suarez, has been my treating physician for my bipolar depression for the last 7 years. Linda, his office manager, called me last night to advise that since I now have CarePlus, they can no longer see me. Linda further clarified that they do not accept CarePlus. I need someone to figure out this issue because Dr. Suarez is the only psychiatrist that has really helped me throughout the years. My next appointment is a month away."
What action(s) should the ICR complete in order to fully assist the member with coordination of care and any education required?
Offer to locate an in-network provider, initiate a standard mental health organization determination if needed, and warm transfer the member to Magellan.
Educate the member the plan provides a 90 day transitional period from an OON to a network provider and offer to locate an in-network provider.
Educate the member they can only see providers in the Magellan network and offer to locate an in-network provider.
Offer to locate an in-network provider, initiate an expedited mental health organization determination if needed, and warm transfer the member to Magellan.
300s - Q6
An ICR receives a call from CPHI, Lisa Simpson, on 08/17/21 at 9:30am. The CPHI states the following:
"Good morning. I'm calling to follow up on my grandfather's authorization request for his manual wheelchair. My grandfather's cane is not as useful as a wheelchair would be. I've noticed that even with a cane his balance is a little off. Please tell me what's going on."
As the ICR, you proceed to conduct your research and confirm the following: The status for the wheelchair authorization reflects as ‘N’ and the authorization comments indicate that measurements along with supporting medical documents were not received. You also confirm the LI screen confirms a denial letter was printed on 8/15/21 at 8:05am.
What action(s) should the ICR complete in order to fully assist the CPHI with coordination of care and any education required?
Educate CPHI the wheelchair request is currently under review and advise of the expedited timeframe (as expeditiously as the member’s health requires but no later than 72 hours)
Educate CPHI the wheelchair request was approved and provide them with the authorization information (auth #, DME vendor name, # of visits, type of service approved, expiration date and applicable copayments)
Educate CPHI on the information regarding the denied authorization and advise of appeal rights which includes how to appeal, appeal filing timeframe, denial reason, and date of denial.
Educate CPHI the wheelchair request was voided due to authorization must be worked by the assigned network.
300s - Q7
An ICR can assist a CPHI or unauthorized caller with initiating an organization determination (C0182/CP094) for applicable items and services.
True
False
120s - Q8
ICRs are not required to contact the support line for review of expedited organization determinations.
True
False
120s - Q9
ICRs should initiate a valid organization determination to the caller when they experience a barrier with a PCP because it is meant to bypass the PCP.
True
False
120s - Q10
An ICR receives a call from a member on 08/24/21 who confirms the following:
"Listen, I really need to see Dr. Goldman, my cardiologist. My heart palpitations have been getting worse and my medicine seems to not be doing what it needs to do. David from my PCP's office was able to squeeze me in to see Dr. Goldman on 08/27/21. He also let me know that he sent the paperwork to you guys so that you can approve my visit. Can you let me know if I can go?"
As the ICR, you proceed to conduct your research and confirm the following: The authorization request for Dr. Patrick Goldman was received on 08/23/21 as a standard request and is in "S" status. You informed the member of your findings and she becomes extremely emotional as she does not want to miss her appointment and states she wants an answer now.
What action(s) should the ICR complete in order to fully assist the CPHI with coordination of care and any education required?
ICR should educate on the authorization standard timeframe and explain the request does not meet expedite criteria; advise of emergency room/urgent care services if the palpitations worsen.
ICR should educate on the authorization standard timeframe and explain to her the determination will be made soon; advise of emergency room/urgent care services if the cough worsens.
ICR should educate that PCP submitted the request standard based on medical necessity, refer the member to speak with the PCP in order for the request to be re-submitted as expedited via the portal and advise of emergency room/urgent care services if the palpitations worsen.
ICR should educate on the authorization standard timeframe, contact the PCP in regards to member’s current condition for coordination of services and advise of emergency room/urgent care services her palpitations worsen; initiate an expedited organization determination if needed.
300s - Q11
An ICR receives a call from a member who confirms the following:
"Listen here son. My power wheelchair isn't working right. I use this thing for 2 hours and then it stops on me. How am I suppose to get around if my scoot scoot isn't working right?! It could be that I broke the battery when I cleaned it with bleach but how do I know? Missy, my late wife, used to do everything for me and after she passed away, I don't know what to do with myself. Please help me."
What action(s) should the ICR complete in order to fully assist the CPHI with coordination of care and any education required?
Confirm with the member if he has spoken to the PCP, verify if a new order has been submitted for the DME repair through the DME portal and educate that a standard organization determination request can be initiated on his behalf.
Confirm if he has spoken to his PCP and offer to contact the office in order to verify if a new order has been submitted for the DME repair through the DME portal. If able to speak to the PCP's office, assist in coordinating the needed item by advising of the need and initiate an expedited organization determination for corresponding DME vendor if needed.
Confirm with the member if he has spoken to the PCP and advise the PCP would need to submit the request to the corresponding DME vendor for review and determination.
Verify if a new order has been submitted for the DME repair through the DME portal and proceed to initiate an expedited organization determination since the member is in need of the item as the scooter does not last long.
300s - Q12
An ICR receives a call from Victor, SNP member, who confirms the following:
"Yo! I'm vising my sister, Gianna, in Jersey and I had a little accident. Hee hee. I was partying a little bit too much and I fell down and busted my hip. I'm so happy I have you all as my insurance because I went to the ER and they took care of me. The only thing is, the discharging ER physician told me I need to see a neurologist within a week because I took a bad hit to the head. My only concern is I don't go back to Daytona until another month from now. The ER doctor gave me the name of a local neurologist that has availability. How can I go see him?"
What action(s) should the ICR complete in order to fully assist the CPHI with coordination of care and any education required?
Probe the member and educate that his PCP can submit an authorization request for a non-participating doctor or the plan can submit the request on his behalf; advise on out of service area coverage.
Probe the member, educate on out of service area coverage and initiate an organization determination for a non-participating provider if needed.
Probe the member and educate that only ER and urgent care services are covered while being out of the service area; therefore, he would need to be in his home area in order to receive treatment.
Probe the member to obtain details of the local neurologist, provide education regarding out of service area coverage and contact the PCP to assist in coordinating the needed service; initiate an organization determination for a non-participating provider if needed.
300s - Q13
An ICR receives a call from Victor, SNP member, who confirms the following:
"Yo! I'm vising my sister, Gianna, in Jersey and I had a little accident. Hee hee. I was partying a little bit too much and I fell down and busted my hip. I'm so happy I have you all as my insurance because I went to the ER and they took care of me. The only thing is, the discharging ER physician told me I need to see a neurologist within a week because I took a bad hit to the head. My only concern is I don't go back to Daytona until another month from now. The ER doctor gave me the name of a local neurologist that has availability. How can I go see him?"
What action(s) should the ICR complete in order to fully assist the CPHI with coordination of care and any education required?
Probe the member and educate that only ER and urgent care services are covered while being out of the service area; therefore, he would need to be in his home area in order to receive treatment.
Probe the member and educate that his PCP can submit an authorization request for a non-participating doctor or the plan can submit the request on his behalf; advise on out of service area coverage.
Probe the member to obtain details of the local neurologist, provide education regarding out of service area coverage and contact the PCP to assist in coordinating the needed service; initiate an organization determination for a non-participating provider if needed.
Probe the member, educate on out of service area coverage and initiate an organization determination for a non-participating provider if needed.
300s - Q14
An ICR receives a call from a member who confirms the following:
"My doctor gave me a piece of paper but I'm not sure what it's called. I just had ankle surgery and he wants me to have physical therapy at some facility. I know he sent everything over to the place and they approved the visits. However, I need a copy of the paper that tells them I need physical therapy three times a week, 1 hour a day, and tells them to focus on my right ankle."
What will the member require to be seen at Alivi Therapy Network?
Referral
Pre-service authorization
Script
None of the above
120s - Q15
Mr. Benedict Cumberbatch, a CarePlus member, has been seeing his PCP for the last two months regarding swelling of his hands and feet. A bone density exam was done which is showing initial signs of bone erosion. His PCP advised Benedict that he needs to see a rheumatologist for further evaluation.
What type of document was the member provided with?
Referral
Pre-service authorization
Script
None of the above
120s