Mapd Jeopardy Jeopardy Template

RIDERS	Complaints, Appeals, & Grivences	Claims	Providers	Random
100 TRUE IF I set up a payment plan or make a one-time payment today, I be able to keep my rider. T or F	100 Standard Verbal Grievance Quality of Care What are the two types of grievances?	100 NOP Mary received a statement from her doctor’s office that says she owes $200. NDP, EOB, NOP	100 PPO has both INN or OON benefits HMO only has INN benefits What is the difference between PPO AND HMO?	100 9 consecutive months How many months can a member use their passport without their plan being disenrolled?
200 If the member's plan does not offer a fitness benefit, or the member does not have a rider available in his/her service area, the request for the benefits will likely be denied. T or F TRUE If the member's plan does not offer a fitness benefit, or the member does not have a rider available in his/her service area, the request for the benefits will likely be denied. T or F	200 Quality of care grievance is a complaint about the care or service received from a medical provider and a layperson believes the incident may have resulted in, or has the potential to result in, a worsened medical condition. What is a quality of care grievance?	200 EOB Mary wants to know why there are paragraphs with other languages on her EOB when her primary language is English. NDP, EOB, NOP	200 gatekeeper - needs a referral open access - you can go to any specialist What is the difference between gatekeeper and open access?	200 72 hours TAT for a Part C Appeal Expedited
300 If the member has not made a payment to pay the balance in full to the current month by the last day of month 2, their Rider will be downgraded effective the last day of Month 2. True or False TRUE If the member has not made a payment to pay the balance in full to the current month by the last day of month 2, their Rider will be downgraded effective the last day of Month 2. True or False	300 72 hours. Standard Coverage Determinations turn around time is?	300 Macro What do we use to see the denial or adjustment code reason?	300 Other than emergency situations, members are responsible for verifying provider deemed status every time, prior to seeking medical treatment. What does a member have to do every time they see a doctor when they have a PFFS (Private Fee For Service) plan?	300 Pay Subscriber Medical claims paid to members will display ______ within the Provider column of the Claims tab in Account Summary.
400 EDSS Where can the rider downgrade letter be found, if it was sent to the member?	400 24 hours Expedited Coverage Determinations turn around time is?	400 NDP Mary states the payment on a claim was denied. NDP, EOB, NOP	400 Yes, you will have to start paying out of pocket when you become stable. NOTE: •As soon as the patient is stable enough to be transferred to a network facility, they must do so or risk paying full costs of further medical care. I have an HMO plan. I went to an OON emergency room when I had a heart attack. I got admitted into the hospital, but now I am stable again. I have not gotten discharged from the hospital. I am still admitted even though I am stable. My question is, will I have to pay out of pocket now that I am stable even though I came here for an emergency.	400 Yes offer both. If member has NO OON benefits, let member know that if they do not have OON benefits, they will pay OOP for all costs to see an OON specialists. If a member calls in and asks about her copayment for a specialist visit, do I offer member in and out of network copays? or just in network? what if member has no OON benefits?
500 False My plan is always going to have the option of a dental, vision and fitness rider but it is up to me to choose if I want to Add it or not. True or	500 TAKE the call yourself. We submit them. Mrs.Shiela wants to express her dissatisfaction with Optum RX Customer service. Would you take the call or warm transfer her to optum RX customer service and let them know the member wants to submit a grievance expressing dissatisfaction of THEIR customer service?	500 Start the Appeal process. If someone calls and has an HMO plan, and went to see a OON provider, and gets a denied claim, what can we offer?	500 It means that you can go to any IN NETWORK PROVIDER without a referral requirement. I have an HMO plan with open access benefits. what does this mean?	500 Walk through the talking points for the NBA and transfer the member to the housecalls program. Do I transfer a member that wants to schedule an house calls? or do I open the "schedule an appointment intent" within maestro to confirm I set up a house calls appointment.

MAPD JEOPARDY

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