Special Services Appeals Jeopardy Template

Medicare	Commercial	Administrative	Operations	Front End
100 What is the name of the level you attach the proof of payment screen print? The effectuation level	100 What is the phone number for filing a verbal appeal? 510 625-4742	100 What is the way to select all text on a document? Cntrl-A	100 How many days do you have to close an inquiry? 5 days is department standards however 10 days is the regulation.	100 Who process the case if a member requests a co-payment refund of an Ambulance transport due to dissatisfaction with the office visit ? Member Case Resolution Center
200 What is the timeframe we need to close our Maximus Post level? Immediately when we recieve the decision or within 3 days, unless it is at the beginning of the month.	200 What is new information and what are the ways to notifiy the member of the new information? New information is any information that was not used in the first review. The information must be provided to the member as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination on review is require	200 What is the deadline time for timesheets? By 10:00am	200 What is LMS? Local Member Services	200 If the member sends in an EOB with no writing on it, what type case is it? Inquiry
300 The new Medicare AOR form went into effect 12/18/12, but the member already has an old AOR on file. Can we use it for this new request? We will accept an old form already on record as long as it contains all the Medicare information requirements that are on the Medicare AOR (both member and advocate sign the form, and the member’s HIC # should be on the form), is still within the year it	300 What is the name of the letter that informs the member of a new reason for denying the claim? New Rationale	300 Who is Ross getting married to on June 1st Kristy	300 What is the California Service Center Handles enrollment and termination related questionfor Medicare and som non-Medicare Accounts	300 A request that is being processed by S.S is found to have been or is being processed by the MCRC Department as well. How would the Special Services proceed with the case? Since the Special Services Department is processing the request, the MCRC would withdraw the request in the Grievance Standard Level. If the member has a complaint, the MCRC would process the complaint. If no complaint, the MCRC would withdraw case. If c
400 Is a KPSA Special Needs member processed as a Medicare member, a non- Medicare with Medi-Cal language, or both? A KPSA Special Needs Program member does not have their Medi-Cal assigned to the Plan. This member is treated as a Medicare Member. The case would be processed as a Medicare Member.	400 What is a balance bill? KP has paid the bill yet the member is getting a bill for a balance.	400 What is the number to report system problems? 1111	400 What is the timeline agreement with R & R for payment request? Two days	400 What is the start date of a case received in Special Services from the MCRC Department? The Claims Dept is part of Health Plan so the moment this issue hit the Claims Department, the case process clock starts ticking. The MCRC department is part of Health Plan so the moment this issue hit the MCRC Department, the case process clock starts ticking. (Immediately)
500 The Medicare member submitted a letter that says that she wants to authorize her daughter to be her representative. The letter is dated, and both the member and the daughter signed the letter. Can we use this? Members do not have to use the Plan’s Medicare AOR form. They can provide the necessary information in other equivalent written notice. It could be CMS’ AOR form, the Plan’s old form, or even a letter from the member. An equivalent written notice is one t	500 Do we process complaints against contracted Kaiser Permanente providers? Yes, Member Services processes all complaints associated with contracted Kaiser Permanente providers.	500 When can a member be provided a benefit clarification letter? This letter can be provided if you can quote from the member’s Evidence of Coverage (EOC). If the benefit is not clearly listed as an exclusion in the members EOC, then request must be taken through the Member Services review process. The Inquiry Letter D	500 What is the case type when a member sends in a letter with a claim that has been paid. Inquiry

Special Services Appeals

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