Question 1

Mr Octopus Squid wants to understand how their excess works. They have OP complementary medicine of £250 and an excess of £250. Member had 5 follow up osteopath sessions which costed £50 each. After paying their excess how much would they have left towards their OP complementary medicine?

60

£0

£200

£100

£250

Accepted Answer

£0

Answer

£200

Answer

£100

Answer

£250

Question 2

A customer has already used their full benefit allowance for a particular treatment. They call asking if they should still receive a pre‑authorisation number for upcoming treatment that is covered by their policy, even though they won’t be reimbursed due to the allowance being exhausted.

Accepted Answer

Yes — still give the pre‑authorisation number because it helps with future queries or if their allowance resets at renewal.

Answer

Only give a pre‑authorisation number if they ask for it twice.

Answer

Decline the treatment entirely since their allowance is used.

Answer

No — there’s no point giving a pre‑authorisation number if their benefit is already used.

Question 3

You’ve confirmed that a customer’s treatment is covered. According to the Emailing Benefit Advice process, what must you do next?

Accepted Answer

Explain that an email will be sent, highlight its importance, offer to go through the details over the phone, confirm their email address, and remind them it’s also available in the MyBupa app.

Answer

Tell the customer to check their online portal without offering an email or verbal explanation.

Answer

Send the email immediately without explanation, as long as you have an email address.

Answer

Only provide benefit advice verbally email is optional and shouldn’t be mentioned unless requested.

Question 4

A member with a Bupa By You policy is referred for a routine knee arthroscopy. Their consultant wants to perform the procedure at an out‑of‑network hospital because “the theatre kit is better, and it’s where they usually operate. ”the member insists they want to stay with this consultant.

Accepted Answer

Decline OON/OOC because consultant preference is not clinical rationale and redirect to an in‑network provider.

Answer

Proceed with an OON request because the customer wants to remain with their consultant.

Answer

Create an HCS: Out Of Contract Queries task because the hospital is outside network.

Answer

Refer to the Out of Network Team because the consultant believes the theatre kit is better.

Question 5

Mrs Angelfish has rheumatoid arthritis and is scheduled for a knee replacement in 2 months after the 90 days grace period. She asks whether the surgery is eligible.

What is the correct decision?

Accepted Answer

Eligible — joint replacement for RA is routinely eligible, even outside the 90‑day window.

Answer

Eligible only if the surgery is scheduled within the 90‑day exception.

Answer

Not eligible — she’s outside the 90‑day grace period.

Answer

Eligible only if she also has a hip replacement scheduled.

Question 6

Mr Starfish calls and says his GP told him he needs a corticosteroid injection and some physiotherapy sessions for “some inflammation in the shoulder.

”When you ask for the diagnosis, he says:

“I’m not sure what it’s called, but the consultant definitely diagnosed something.”

What should you do?

Accepted Answer

Approve the injection because he says a diagnosis exists.

Answer

Decline because inflammation is considered chronic.

Answer

Ask him to find out the name of the diagnosed condition and call back.

Answer

Approve up to two injections as long as there’s exercise therapy involved.

Question 7

Mr Tornado has been referred by Vgp to see a T&O consultant but the member would like to see an acupuncturist instead.

What should you do?

Accepted Answer

Request a new referral

Answer

Offer DA

Answer

Authorise the treatment

Answer

Tell member they have to see the T&O

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