Question 1

A member has CareOne Plus in Duval county. Which of the following is TRUE about the member's dental benefit in 2023?

Accepted Answer

The member can get 1 set of bitewing x-rays per calendar year

Answer

Deep cleaning limited to 1 quadrant only per year

Answer

Amalgam or composite filling are limited to 3 per year

Answer

$0 copay - Root Canal - up to 1 per calendar year

Question 2

A new member from Palm Beach County just enrolled in our CareBreeze plan. They call to inquire what type of vision benefits are included with their plan. What information will you provide?

Accepted Answer

$0 copayment for refraction, routine exam up to 1 per year. $300 maximum benefit coverage amount per year for contact lenses, eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames or 2 pairs of select eyeglasses at no cost. Member is allowed to substitute 1 pair of eyeglasses for 1 pair of select prescription sunglasses at no cost. Eyeglasses include ultraviolet protection and scratch resistant coating.

Answer

$0 copayment for refraction, routine exam up to 1 per year. $180 maximum benefit coverage amount per year for contact lenses, eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames. Eyeglasses include ultraviolet protection and scratch resistant coating.

Answer

$0 copayment for refraction, routine exam up to 1 per year. $50 maximum benefit coverage amount per year for contact lenses, eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames or 1 pair of select eyeglasses at no cost. Eyeglasses include ultraviolet protection and scratch resistant coating.

Question 3

The only time a member is required to pay full cost for dental or vision services is when the service is obtained from an out-of-network provider.

Accepted Answer

true

Answer

false

Question 4

You should call ____________ to verify how many times a member has received a specific service so far this year.

Accepted Answer

Aflac

Answer

CPHP's claims department

Answer

the provider

Answer

Member Services

Question 5

Aflac should be contacted if a provider who appears in the search tool tells a member they don't accept CarePlus plans.

Accepted Answer

false

Answer

true

Question 6

An Org Determination request should be filed for all situations below EXCEPT:

Accepted Answer

When a request or claim has already been denied

Answer

When a member expresses the inability to afford a non-covered service with a VAIS discount

Answer

When the member believes or argues an item or service should be covered or paid for by the plan

Answer

When a member has "used up" all of their plan benefits

Question 7

The plan may take up to __________ for standard or ____________ for expedited Org Determinations to review and make a decision.

Accepted Answer

14 calendar days; 72 hours

Answer

14 calendar days; 24 hours

Answer

30 calendar days; 10 calendar days

Question 8

Dental Org Determination requests should always have a status of:

Accepted Answer

Open

Answer

Closed

Answer

Internal

Answer

Pending

Question 9

Vision Org Determination requests should always have a status of:

Accepted Answer

Open

Answer

Internal

Answer

Pending

Answer

Closed

Question 10

An ICR should capture as many details from the member as possible, including provider information, impacted tooth number (if available), CPT codes (if available), when submitting an Org Determination request.

Accepted Answer

true

Answer

false

Question 11

A member contacts CarePlus and mentions that, after being diagnosed with cataracts yesterday, their optometrist has referred them to see a specialist. The doctor they were referred to is a little too far for them to travel to, and they'd like assistance finding a closer provider. How will you assist the member?

Accepted Answer

Advise the member that medical eye services must be performed by an ophthalmologist, and you will be happy to transfer them to the main Member Services queue for assistance.

Answer

Advise the member since they have exhausted their eye exam benefit at the optometrist, they may not obtain an eye exam from any other vision provider until next year.

Answer

Submit a C0262 for the evaluation and any necessary procedures related to the cataracts.

Answer

Find the member an in-network specialist using the Argus Provider Search tool and advise of any applicable discounts.

Question 12

A member calls on Friday morning and indicates they are in extreme dental pain. He states his dentist submitted the request to have his painful tooth extracted at the beginning of the week, but he just spoke with the office and they said they still have not received the authorization to perform the extraction. How will you assist the member?

Accepted Answer

Review the member's benefits to verify if surgical extractions are a covered benefit, and educate that pre-authorizations are not required for surgical extractions.

Answer

Call the support line to have the existing Org Determination request changed to an expedited request and educate the member on the expedited timeframe.

Answer

Contact Argus for the status of the authorization request, then perform outreach to the dental provider to suggest requesting expedited review.

Answer

Submit a new expedited Org Determination for the extraction and educate on the expedited timeframe.

Question 13

A member calls on the 14th of the month to request the status of an authorization request for partial denture. You research and find the expedited request was submitted on the 13th and is still pending. What should you advise the member?

Accepted Answer

The request is still under review and a determination will be made no later than the 16th.

Answer

The request for dentures will be approved on the 28th and will expire 90 days after that date.

Answer

The request is still under review and a determination will be made no later than the 28th.

Answer

The request for dentures will be approved on the 16th and will expire 90 days after that date.

Question 14

A member calls stating their request for a complete set of dentures was denied. They received a letter dated 10 days ago, and they don't know what to do next. How do you assist the member?

Accepted Answer

File an appeal

Answer

Advise the member to reach out to Argus for next steps

Answer

File a grievance

Answer

Submit a new Org Determination

Question 15

A member's nephew calls in and sounds upset. He states that his uncle ordered a new pair of glasses and had requested the lenses be no-line bifocals. He just picked them up and discovered they are a standard bi-focal pair of lenses. He wants the lenses replaced. You verify he is listed as an AOR on the member's account. What will you do to assist the caller?

Accepted Answer

Document a G011M, contact the vision provider to inquire if they will replace the glasses for the member, and open an Org Determination request if the provider is unwilling to assist.

Answer

Document a C0262, contact Argus to inquire if a replacement pair of glasses can be obtained for the member, and open an Org Determination request to supply Argus with the details of the request.

Answer

Document a C0039, contact the vision provider to inquire if they will replace the glasses for the member, and open an Org Determination request if the provider is unwilling to assist.

Answer

Document a G077M, contact the vision provider to inquire if they will replace the glasses for the member, and open an Org Determination request if the provider is unwilling to assist.

Question 16

A member called after seeing an in-network dental provider who advised she would need 2 root canals. The provider took over 3 weeks to submit the authorization request, and when she finally went in for the procedure, the tooth had worsened and needed to be extracted completely. How do you document this call?

Accepted Answer

CP558 - Quality of Care against the provider

Answer

CP558 - Quality of Care against Argus

Answer

G077M - Quality of Service against the provider

Answer

G011M - Benefits Package against CarePlus

Question 17

Members can only submit an expedited appeal if they have a disability, express illiteracy, or are unable to submit the appeal in writing.

Accepted Answer

false

Answer

true

Question 18

C0193 is used when educating a member about the appeals process and when submitting an oral appeal request.

Accepted Answer

false

Answer

true

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