Smmc Good Cause Refresher

10 Questions | Total Attempts: 478

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Smmc Good Cause Refresher

Questions and Answers
  • 1. 
    Caller is locked in and says: " I never picked this plan!  You all put me in it!  My doctor, that I really like, doesn't take this plan and has never taken it!  I've been with the same doctor for years, I don't want to change."  Which GC would apply?
    • A. 

      GC1

    • B. 

      GC8

    • C. 

      GC1612

    • D. 

      GC9

  • 2. 
    Caller is locked in and says:  "I have an eye disease and need a cornea transplant. I found one eye surgeon in my area but he doesn't take my plan. He's the only one in the area that knows how to do this surgery. Can I change my plan?"  Which GC would apply?
    • A. 

      GC1610

    • B. 

      GC9

    • C. 

      GC4

    • D. 

      GC5

  • 3. 
    A member has called several times and states their doctor will stop taking their current plan starting next month.  You look in HealthTrack and the PCP is still showing with the curent plan, so the GC1(Provider No Longer with Plan) is denied.  You explain this to the caller and they state they have a letter from the doctor's office that states the PCP is no longer taking the plan.  What should you do next?
    • A. 

      Tell the caller to fax the letter so it can be sent to AHCA for verification.

    • B. 

      Tell the caller they have to wait until open enrollment to change.

    • C. 

      Refer the caller to the health plan to request a new doctor.

    • D. 

      Tell the caller to get an out of network authorization.

  • 4. 
    Caller is locked in and says: The company that delivers my meals told me they will stop taking my plan next month. I really like them because they are always on time and they make good food. Can I change my plan to a plan they will take? Which Good Cause would you use?
    • A. 

      GC4

    • B. 

      GC1

    • C. 

      GC9

    • D. 

      GC17

  • 5. 
    Caller is locked in and says:  "I have HIV and my doctor told me to change to Clear Health Alliance, I need that to start soon because all of my new specialists take that plan."  Which GC would apply?
    • A. 

      GC4

    • B. 

      GC17

    • C. 

      GC9

    • D. 

      GC5

  • 6. 
    Members that change with a Good Cause Reason get an additional 90 days to try out the new plan.
    • A. 

      True

    • B. 

      False

  • 7. 
    Caller is locked in and says:  "I just got notified that I am a candidate for a kidney transplant.  I need to change the plan because the surgeon doesn't take my plan.  They want to schedule the surgery ASAP, because my kidneys are not working and the dyalisis treatment is not working anymore.  The last time I called, you all told me I had to do some complaint process, but I just don't have time for that.  I need the plan changed ASAP! How should you proceed?
    • A. 

      Tell the caller they must complete the grievance process first, before the Good Cause can be submitted to AHCA.

    • B. 

      Tell the caller they must wait until open enrollment to change the health plan.

    • C. 

      Refer the caller to the Area Medicaid Office for an exemption.

    • D. 

      For extreme circumstances, submit a supervisor task to verify if the SNU needs to review the issue. In the meantime, advise the caller to contact the plan case manager.

  • 8. 
    One of the GC9 questions in HealthTrack asks: Was the member mandatorily assigned to the current plan?  How do you determine this?
    • A. 

      Look in FMMIS.

    • B. 

      Ask the caller if they picked the plan or not.

    • C. 

      Look in HealthTrack History.

    • D. 

      Just answer "yes" to the question, so that the GC9 can be submitted.

  • 9. 
    Caller is locked in and says: I just moved from Tallahassee to Wakulla and I need to change my plan so I can see the doctor in Wakulla. I never received my open enrollment letter because I think it was sent to the incorrect address. Can I change my plan? Which Good Cause would you use? 
    • A. 

      GC4

    • B. 

      GC5

    • C. 

      GC11

    • D. 

      GC1612

  • 10. 
    Caller is locked in and says: "The specialist I am seeing keeps rescheduling my appointments and prescribing medications that makes me feel worse. I called in to change my plan almost two months ago so I can see a different specialist and I was told the plan would take effect the 1st of the following month.  When I went to see the new specialist after the 1st, I was told my plan had not changed so I have had to continue seeing the same specialist under my current plan." You look and there was a call for a plan change, but no change was processed by the system.  How do you proceed?
    • A. 

      Submit a request for GC4 because the specialist is not providing effective care and this good cause gets approved by AHCA. AHCA will ensure the provider does not reschedule anymore appointments and the good cause gets approved.

    • B. 

      Call a supervisor/lead for approval to use a GC1610, because you can see the request was placed and just did not process, and GC1610 can be approved by AHS.

    • C. 

      Advise the caller to speak with the specialist about their ineffective treatment.

    • D. 

      Process the request with GC1621, because the provider is delaying treatment and denying proper services.

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