Smmc Good Cause Refresher 2

1. What is the grievance?

The grievance is a formal complaint filed by the recipient with the plan concerning issues.

The grievance is a formal complaint made by the plan against the recipient for complaining.

The grievance is when the recipient calls AHS and complains about the plan.

The grievance is a court setting in which the member, health plan, and AHCA meet.

2. Caller is locked in and says: "My doctor passed away last week. I want to continue going to the same practice but they take a different plan. Can you help me?" How do you proceed?

Advise the caller of their open enrollment dates and end the call.

Create a supervisor task and include the PCP name and explain the situation.

Submit request to process the plan change using GC4 because the provider is no longer able to provide effective care.

Submit request to process the plan change using GC8 because the caller is unable to access the provider.

3. Caller is locked in and says: "I need to change my plan. I went to the health department months ago and there was a lady sitting in the parking lot with a table. She said she worked for XYZ plan and before I could see the doctor, I needed to pick a plan. She said all I would need to do is sign up and the doctor would see me. I signed up with her plan and got a free gas card. She did not tell me there were other plans to choose from. I just found out my doctor doesn't even take this plan." How would you proceed?

Advise the caller to contact the plan so they can resolve the issue.

Process plan change request with GC1624.

Process plan change request with GC3.

4. Caller is locked in and says: "I'm 95 years old and my daughter used to be able to come in with me when I go for my Behavioral Management. I feel safer and more comfortable when she is there. The people I see now do not let her talk or help and I feel she knows me best and should be able to help with my Behavioral Management. I want to change my plan." Which GC should you use?

GC4

GC14

GC7

5. Caller is locked in and says: "Dr. Stanley is no longer taking Magellan. I only picked that plan to see Dr. Stanley and now he says he takes Staywell. Since he doesn't take Magellan, I want to change my plan to Humana Medical with Dr. Flan." You look in HealthTrack and verify Dr. Stanley no longer accepts Magellan Specialty Plan but is accepting Staywell Health Plan. How would you proceed?

Process the plan change with GC1 to Humana Medical Plan with the new provider, Dr. Flan.

Process request with GC9.

Process request with GC1610, and document in the notes that the caller does not want the original provider.