Provider Contract Status Letters

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Provider Contract Status Letters


Froggy Jumps Provider Contract Status LettersVersión en línea Test your knowledge on Provider Contract Status Letters with this fun quiz! por Training 1 There is a job aid available to assist Representatives with inquiries related to the creation of PCS letters. What is the name of the Job aid? a CAA Requirements for Member Notification of Provider Contract Status b PCS FlowChart c SF Routing List Commercial Medicaid 2 In Facets, where would a Representative search for SMA and UMC Providers? a Network Group b IPA c Provider Notes 3 In what instances should a PCS letter be generated? a When a Provider calls in to check on their own network status. b When a member calls in for a PCP Change and the change was not made in the CSE. c When a member wants a list of Providers or Healthcare Facilities. 4 A member reported that a provider listed as in-network at the time of their visit now appears out-of-network on the EOB and is no longer in the directory. What should be noted in the remarks section of the service form? a The member's phone number. b Include the directory and & viewed, claim number, service date, claim amount, provider name, and NPI c The representative's name and employee ID. 5 In which instances would a PCS letter NOT be sent? a When a member calls to check if a provider is in-network. b When a member calls for a PCP change and it was made in the CSE during the call. c When a member asks about a specific facility is in-network. 6 When a subscriber or third party calls on behalf of a dependent member who is under the age of 12, what information is populated on the Member Response Letter template? a The dependent's school address and guardian's phone number. b The third party's contact information and relationship to the member. c The subscriber's (member's) mailing address on file and email. 7 If a call is disconnected but enough provider information was gathered before the call disconnected, what is required? a A PCS letter must still be generated b No action c Supervisor review 8 If a member asks about 3 different providers, how many letters should be sent? a One b Two c Three 9 Which of the following is not a valid source for checking provider contract status? a Yelp b Facets c Provider Directories 10 What does the letter "T" in Facets notes indicate? a The note is temporary b The note no longer applies as of a specific date c The provider is in training 11 If a provider is not found in the directory but is in Facets, what is this called? a Match b Mismatch c Duplicate 12 What is required for a member to see an Overflow Provider? a PCP approval b Online appointment c Referral or Prior Authorization 13 Who sends the PCS letter in case of a mismatch for Sierra Representatives? a Provider Advocate Box b Member Services c The Provider 14 What is the correct action if a provider is not found in either Facets or the directory? a Send a Contracted letter b Send a Non-Contracted letter c Escalate to supervisor 15 When should a letter be sent at the Group Level? a When the group is not in Facets b When all listed providers are active c When the member requests it 16 What should be checked in Facets to see if a provider is excluded from a group? a Provider Notes and Group Notes b Provider's license c Provider's specialty 17 For plan years on/after January 1, 2022, what should happen if a member receives eligible services from a non-participating provider after being told by customer service or an online directory that the provider was in-network? a The claim should be denied due to provider being out-of-network. b The claim should be paid at the out-of-network rate with no cost share. c The claim should be paid at the in-network rate with cost share applied to in-network accumulators. 18 Which of the following statements is TRUE regarding the creation of PCS letters for vision and dental services? a PCS letters must be sent for all adult and pediatric dental and vision inquiries. b Adult Vision and Dental aren't covered by PCS letters and don't require one. c Reps should avoid using the HPN Dental Directory and EyeMed Directory when searching for providers. 19 When assisting a member with a provider inquiry and they are opting to use their choice plus benefits, which of the following is the correct procedure for verifying provider contract status and generating a PCS letter? a Use Facets to confirm the provider's status and generate the letter using the NPI. b Search for the provider in Facets and skip the PCS letter if the provider is not found. c Use the Choice Plus Directory to confirm provider status and enter details manually for the letter. 20 Under what circumstances should a Contracted or Non-Contracted letter be sent at the individual level, and when is it appropriate to send a letter at the group level? a A Contracted letter is sent only if the provider is listed in Facets; Group letters are preferred. b Non-Contracted letter if the provider isn’t listed; use a Group letter if all providers are active c A Non-Contracted letter is sent if the provider is inactive in Facets; Group letters are not allowed

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Provider Contract Status Letters

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Provider Contract Status LettersVersión en línea

por Training

There is a job aid available to assist Representatives with inquiries related to the creation of PCS letters. What is the name of the Job aid?

In Facets, where would a Representative search for SMA and UMC Providers?

In what instances should a PCS letter be generated?

A member reported that a provider listed as in-network at the time of their visit now appears out-of-network on the EOB and is no longer in the directory. What should be noted in the remarks section of the service form?

In which instances would a PCS letter NOT be sent?

When a subscriber or third party calls on behalf of a dependent member who is under the age of 12, what information is populated on the Member Response Letter template?

If a call is disconnected but enough provider information was gathered before the call disconnected, what is required?

If a member asks about 3 different providers, how many letters should be sent?

Which of the following is not a valid source for checking provider contract status?

What does the letter "T" in Facets notes indicate?

If a provider is not found in the directory but is in Facets, what is this called?

What is required for a member to see an Overflow Provider?

Who sends the PCS letter in case of a mismatch for Sierra Representatives?

What is the correct action if a provider is not found in either Facets or the directory?

When should a letter be sent at the Group Level?

What should be checked in Facets to see if a provider is excluded from a group?

For plan years on/after January 1, 2022, what should happen if a member receives eligible services from a non-participating provider after being told by customer service or an online directory that the provider was in-network?

Which of the following statements is TRUE regarding the creation of PCS letters for vision and dental services?

When assisting a member with a provider inquiry and they are opting to use their choice plus benefits, which of the following is the correct procedure for verifying provider contract status and generating a PCS letter?

Under what circumstances should a Contracted or Non-Contracted letter be sent at the individual level, and when is it appropriate to send a letter at the group level?