CMS TEST 51 Questions with Verified Answers
My doctor says he
filed a claim and
You did not pay. I
want him paid,
who do I need to
talk to? -
... [Show More] CORRECT ANSWER This is an Claims appeal. The rep
should recognize this is an appeal
and offer to start the appeal
process for them and ask for basic
questions. Info asked should
include provider info.
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Located?
Medicare Ops Portal/
WP -CG&A & Billing
I need to get a Pap
test, can I go to my
gynecologist to do
this? - CORRECT ANSWER Yes, they can, no PA required. Is
your Gynecologist in network?
Yes , no need for referral
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WORKBOOK & EOC - Chapter 3 Sec2.2
I want to get a flu
shot, where can I
go to get it and
what will it cost
me? - CORRECT ANSWER They can go to the PCP, their
pharmacy or any in network
pharmacy and cost will be zero. It
is part b coverage, no cost
associated to it, zero cost.
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Located?
SOB & EOC -
Chapter 4
I need to get a
Hepatitis B shot,
where can I go and
how much will it
cost me? - CORRECT ANSWER They can go to the PCP, their
pharmacy or any in network
pharmacy and cost will be zero. It
is part b coverage, no cost
associated to it, zero cost
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Located?
SOB & EOC -
Chapter 4
I received a letter
telling me it is time
for a mammogram,
what is that, how
do I get one, and
how much will it
cost. - CORRECT ANSWER Breast cancer screening
(mammograms) Covered services
include: One baseline
mammogram between the ages of
35 and 39 One screening
mammogram every 12 months for
women age. Go to imiging center,
PCP. There is no coinsurance,
copayment, or deductible for
covered screening mammograms.
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Located?
SOB & EOC.
Chapter 4
Someone called me
and they want to
do something
called an HRA? - CORRECT ANSWER What is that and
why do I need one?
HRA = Health Risk Assessment, it
is a questionnaire to help us
understand what your healthcare
needs are . These assessments
are done by Nurses. This
assessment is required by
Medicare. The assessment helps
us identify services that you may
need and that we can provide.
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Located?
Med Ops
Portal/
WP(HRA)/MOC
WP
The agent talked
about something
called the Model of
Care when he was
here, what does
that mean? - CORRECT ANSWER The Model of Care is Centene's
plan for delivering our integrated
care management program for
members with special needs. It is
the architecture for care
management policy, procedures,
and operational systems.
MOC improves the member
experience by:
- Guiding members to the right
level and site of care
- Helping the member (and their
care givers) to better self-manage
their health
- Assisting members with getting
access to the care that they need
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Located?
Med Ops
Portal/ Call
Flow: Model of
Care
What do you
require of me in
this model of care? - CORRECT ANSWER We need your participation in the
assessment and setting your
goals, then working with us and
your doctors to achieve those
goals, which is better health and
quality of life for you.
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Located?
Med Ops
Portal/ Call
Flow: Model of
Care
I called my
cardiologist to get
an appointment
and his office says
it will be 3 months
before I can get in,
I need to see him
before then - CORRECT ANSWER It is a grievance, talking about
practice guidelines/ Provider
manual (new Medicare manual)
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Located?
Med Ops
Portal/ WP -
CG&A - EOC
I want to disenroll
from the plan, will
you help me? - CORRECT ANSWER There are a few ways you can go
about disenrolling from our
Medicare Advantage plan:
1. Enrolling in another plan
2. Calling 1-800-MEDICARE.
3. Filling out and signing a
disenrollment letter that we can
send to you
4. Mailing or faxing a signed
written notice to [PLAN NAME]
Advantage at 877-941-1931
Enrollment change will be
processed for the 1st of the
next calendar month. You will
still be covered by [Plan Name]
Advantage until that time.
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Located?
Med Ops
Portal/ Call
Flow: Medicare
Disenrollments
I am interested in
enrolling in the
plan, will you help
me? - CORRECT ANSWER Yes. We can have our licensed
sales agent call you to enroll in
our Medicare Advantage plan. You
can also download the application
from the website and mail it to us.
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Located?
Med Ops
Portal/ Call
Flow:
Prospective
Medicare
Member -
Website/
Enrollement
You denied my
surgery and I want
to file a complaint - CORRECT ANSWER Appeal, we will help you fill out an
appeal form and forward it to the
central review team. This will also
be a grievance
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Located?
Appeal form on
the website;
EOC Chapter 9,
Section 6.3 -
CG&A - WP
Can I get my
medications
delivered to my
home? - CORRECT ANSWER Yes we have 90 day mail order.
Enroll in mail order over the
phone. The prescriptions can be
mailed or faxed in from the
doctor. You can save money this
way. It is charged as a one month
copay. (FORM AVAIL IN
SHAREPOINT) (MO will appear on
formulary) (homescripts)
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Located?
EOC/ Chapter 5
Sec2.3
I received a bill
from a laboratory,
what do I do? - CORRECT ANSWER SNP Plan no members
responsibility. Tell the member
that they will not be responsible
for the bill. Mail it or fax it or
gather the information over the
phone
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Located?
Med Ops
Portal/ Work
Process:
Balance Billing
How do I order the
OTC items the
agent says I have? - CORRECT ANSWER Pull the OTC form from the
website and ask them if they have
the otc. OTC should be on the
website
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Located?
Website/
Resourse
Workbook
I got something in
the mail, it is an
ANOC, what is
this? - CORRECT ANSWER ANOC stands for Annual Notice Of
Change and it tells you what
changes will be made in your
benefits on January 1, 2015
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Located?
Website
I got a letter in the
mail that says a
medication I am
taking is not going
to be on the
formulary and I
should call my
doctor? Why is my
drug being
removed and what
can I do to keep
taking it? - CORRECT ANSWER Yes we wanted to be sure you
knew that this medication will not
be covered next year so that your
doctor can find a medicine that is
covered that will work for you.
Our formulary changes each year
and our committee that designs
the formulary reviews lots of data
and drug information in order to
design a formulary that will meet
our members needs and be
approved by CMS. If your doctor
feels that this medication is better
for you than the other similar
drugs on our formulary he or she
can file for an exception and we
will review and make a decision
on whether or not we will
continue to cover the medication
for you. Please do keep in mind
we have medication on the
formulary that is indicated for
treatment of your condition as
well.
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Located?
EOC/ Chapter
5, Section 6.2 &
formulary
transtion fill
I want to stay with
the plan, what do I
need to do for
January? - CORRECT ANSWER If you want to stay with us next
year, it's easy - you don't need to
do anything. If you don't make a
change, you will automatically
stay enrolled in our plan. ** if
they enroll in another plan,
loose eligibility, move out of
area
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ANOC Pg 2.
I want a private
room in the
hospital, how do I
get that? - CORRECT ANSWER Your doctor will need to certify
that it is medically necessary for
you to have a private room
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Located?
EOC/ Chapter 4
What is my
inpatient hospital
deductible cost? - CORRECT ANSWER Your impatient hospital
deductible depends on your level
of Medicaid if Medicaid pays for
your Medicare deductibles and
coinsurance you will pay nothing
for impatient hospital services.
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Located?
EOC &
workbook
I am diabetic and
my doctor wants
me to take Medical
Nutrition Therapy,
is this covered and
how much will it
cost me? - CORRECT ANSWER Yes it is covered under the
preventative services benefit at
no cost to you.
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Located?
EOC
I was visiting my
daughter in North
Dakota and had to
have medication,
the pharmacy
made me pay, what
shall I do? - CORRECT ANSWER Check formulary first. Contact the
plan, Request documentation, and
we will complete the DMR form
for Argus.
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Located?
EOC Chapter 7
/ Med Ops
Portal Forms
I am an LIS level 4
what are my costs
for medical visits
(OHIO , Georgia,
and Florida) - CORRECT ANSWER LIS only applies only applies to RX
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Located?
LIS WP
What dental
benefits do I have? - CORRECT ANSWER 2015 Summary of Benefits
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Located?
Workbook &
SOB & EOC
My doctor wants to
put me in the
hospital for mental
health reasons,
what are my
benefits? - CORRECT ANSWER 2015 Summary of Benefits - any
cost would be dependent upon
your Medicaid Eligibility
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Located?
Workbook &
EOC & SOB
I just had cataract
surgery and my
doctor says I need
glasses, what are
my cost? - CORRECT ANSWER one pair of glasses or contacts
after surgery
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Located?
Workbook &
EOC & SOB
I need a ride to the
pharmacy to get
my prescriptions,
is that covered? - CORRECT ANSWER Yes, it is covered only if they
schedule it at the time they are
making the apt.
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Located?
Workbook &
SOB
I want obesity
counseling, is it
covered and what
would it cost? - CORRECT ANSWER If you have a body mass index of
30 or more, we cover intensive
counseling to help you lose
weight. This counseling is covered
if you get it in a primary care
setting, where it can be
coordinated with your
comprehensive prevention plan.
Talk to your primary care doctor
or practitioner to find out more.
There is no coinsurance,
copayment, or deductible for
preventive obesity screening and
therapy
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Located?
EOC Chapter 4
I need a PSA
(Prostate-specific
antigen) test, is it covered and what
will it cost? - CORRECT ANSWER Medicare-covered zero cost
sharing preventive services - $0
copay
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Located?
EOC - SOB
(End of Section
2)
I want help to quit
smoking, does the
plan provide
anything and if yes
what is the cost? - CORRECT ANSWER Smoking and tobacco use
cessation (counseling to stop
smoking or tobacco use) If you
use tobacco, but do not have signs
or symptoms of tobacco-related
disease: We cover two counseling
quit attempts within a 12-month
period as a preventive service
with no cost to you. Each
counseling attempt includes up to
four face-to-face visits. If you use
tobacco and have been diagnosed
with a tobacco-related disease or
are taking medicine that may be
affected by tobacco: We cover
cessation counseling services. We
cover two counseling quit
attempts within a 12-month
period; however, you will pay the
applicable cost-sharing. Each
counseling attempt includes up to
four face-to-face visits.
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Located?
EOC
Why do you cover
the generic version
of my drug but not
the brand? - CORRECT ANSWER https://cnet.centene.com/sites/MOR/Team/CC/Training%20Resources/2020%20Medicare%20New%20Hire%20Training/Week%204/Prescription%20Drug%20Module/Prescription%20Drug%20Module%202020.pdf
What is Silver
Sneakers? - CORRECT ANSWER A health club membership. EOB
can reprinted or mailed or they
can get a pharmacy coordinator to
get the info
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Located?
Workbook
My first language
is Spanish , I need
my material in
Spanish - CORRECT ANSWER I will put the language indicator in
the system and order your
material to be delivered in
Spanish, in the interim the
material is on the website in
Spanish
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Located?
Alternate
material
request WP
My LIS level is 3
what are my brand
name drug copays? - CORRECT ANSWER LIS Cross Walk - $0
I did not receive
my Part D EOB this
month and need to
know what my
TROOP is? - CORRECT ANSWER EOB can reprinted or mailed or
they can get a pharmacy
coordinator to get the info
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Located?
Curretn TrOOP
WP
My PCP is not
accepting your
plan what are my
options? - CORRECT ANSWER Offer to provide PCP's options,
and then get PCP's name and send
to Network to outreach for
contracting or education if in
network
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Located?
PCP change -
WP
I received an EOB
in the mail and it
says you paid Dr.
Garcia for a visit, I
did not have an
appointment with
Dr. Garcia, I don't
know who she is. - CORRECT ANSWER Gather the information, then
advise member that you will
investigate and keep them posted,
if there is a claim, then we would
send to SIU, if no claim, then we
want to get a copy of the EOB and
check and see if delivered to
appropriate member
Dr. Hernandez said
he did not have
time to review all
my medications, I
am scared to take
Quality of Care Grievance and
member services should gather
info and route info to grievance
team, advise member of process
and when to expect contact,
all these
medications
together. - CORRECT ANSWER member services should outreach
to Care Manager immediately as
member may not be taking
medication that is needed or may
have DDI issues
New Question:
If a member wants to pay their monthly premium in advance, can they? - CORRECT ANSWER Yes. A member can pay their monthly premium in advance.
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Located?
(Source: Per Naomi Goddard, Enrollment Dept.)
New Question:
What is IRMAA? - CORRECT ANSWER IRMAA stands for Income Related Monthly Adjustment Amount (Part D-IRMAA). It applies to Part D plans and is a premium amount, separate from the Part D plan's monthly premium, for individuals whose incomes meet specific thresholds.
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Located?
(Source: Medicare Managed Care Manual on CMS.gov site)
New Question:
Who determines how much IRMAA one has to pay? - CORRECT ANSWER The Social Security Administration assesses the amount annually based on the enrollee's available tax information.
The plan does not collect the Part D-IRMAA as part of its premium. Typically, individuals pay the Part D-IRMAA through their Social Security, Office of Personnel Management or Railroad Retirement Board (RRB) benefit withholding. Some enrollees are directly billed for their Part D-IRMAA through invoices sent by CMS or the RRB. All Part D enrollees who are assessed the Part D-IRMAA are required to pay the IRMAA, even if the Part D coverage is provided through an EGHP.
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Located?
(Source: Medicare Managed Care Manual on CMS.gov site)
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