Smmc Good Cause New Hire Practice

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Smmc Good Cause New Hire Practice - Quiz


Quiz Description


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.

      GC17

    • B.

      GC1622

    • C.

      GC4

    • D.

      GC9

    Correct Answer
    D. GC9
    Explanation
    GC9 would apply in this situation because it states that the caller wants to keep their current doctor and does not want to change. The caller is expressing dissatisfaction with being put into a plan that their doctor does not accept, indicating a desire to remain with their current doctor.

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  • 2. 

    Caller is locked in and says:  "I have three surgeries that need to be performed consecutively on my spine but my plan only covers the first two. My surgeon advised me all three procedures would be covered under a different plan. Can I change my plan?"  Which GC would apply?

    • A.

      GC1620

    • B.

      GC9

    • C.

      GC4

    • D.

      GC14

    Correct Answer
    D. GC14
    Explanation
    The correct answer is GC14. This GC states that a member can change their plan if they have a change in health status that necessitates a different level of care. In this case, the caller's surgeon advised them that all three procedures would be covered under a different plan, indicating a change in health status. Therefore, the caller would be eligible to change their plan to ensure coverage for all three surgeries.

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  • 3. 

    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."  You verify an active HIV span in the case. Which GC would apply?

    • A.

      GC4

    • B.

      GC17

    • C.

      GC9

    • D.

      GC1622

    Correct Answer
    B. GC17
    Explanation
    The correct answer is GC17. This is because GC17 specifically addresses the situation where a caller is locked in and requests a plan change due to a medical condition, such as HIV, and the caller's doctors are in-network with the requested plan. In this case, the caller has stated that their doctor recommended changing to Clear Health Alliance and that all of their new specialists accept that plan. Therefore, GC17 would apply in this situation.

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  • 4. 

    What should we make sure the member has done before attempting to process a Good Cause plan change?

    • A.

      Ensure the member has called the AHCA Medicaid Helpline to file a complaint.

    • B.

      Ensure the member deserves a plan change.

    • C.

      Ensure the member has contacted the plan first to see if the issue could be resolved.

    • D.

      Ensure the member is 18 years or older.

    Correct Answer
    C. Ensure the member has contacted the plan first to see if the issue could be resolved.
    Explanation
    Before attempting to process a Good Cause plan change, it is important to ensure that the member has contacted the plan first to see if the issue could be resolved. This step is necessary as it allows the member to explore potential solutions or alternatives within their existing plan before considering a plan change. It promotes effective communication and problem-solving between the member and the plan, ensuring that all options are explored before proceeding with a change.

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  • 5. 

    Members that change with a Good Cause Reason get an additional 120 days to try out the new plan.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Members who change their plan with a Good Cause Reason are given an additional 120 days to try out the new plan. This means that they have an extended period of time to evaluate whether the new plan meets their needs and if they are satisfied with it. This provision allows members to make informed decisions about their healthcare coverage and ensures that they have ample time to assess the suitability of the new plan.

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  • 6. 

    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 dialisis 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 AHCA Medicaid Helpline 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.

    Correct Answer
    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.
    Explanation
    The correct answer is to submit a supervisor task to verify if the SNU needs to review the issue. This is because the caller is in an urgent situation where they need a kidney transplant as soon as possible. The caller's current health plan does not cover the surgeon they need, so a plan change is necessary. However, the caller does not have time to go through the complaint process. By submitting a supervisor task, the issue can be escalated and reviewed quickly. In the meantime, the caller should be advised to contact their plan case manager for further assistance.

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  • 7. 

    Caller is locked in and says: "I need to change my plan as soon as possible. This doctor is the only provider in the area that accepts my plan and my condition has actually worsened under their care. I have documentation to show my condition has significantly worsened. Can I change my plan? Which Good Cause can you use?

    • A.

      GC9

    • B.

      GC4

    • C.

      GC1620

    • D.

      GC17

    Correct Answer
    B. GC4
    Explanation
    The caller states that their condition has worsened under the care of the doctor who is the only provider in the area that accepts their plan. They also mention having documentation to support their claim. Based on this information, Good Cause 4 (GC4) would be the appropriate option. GC4 allows for a plan change when the enrollee's health condition has significantly worsened under the care of a provider in the network.

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  • 8. 

    Caller is locked in and says: The only provider in my area that takes my plan is over an hour away. My friend sees a doctor right around the corner from me but that doctor doesn't accept my plan.  Can I change my plan so I can see a provider closer to me? Which Good Cause would you use? 

    • A.

      GC4

    • B.

      GC1622

    • C.

      GC17

    • D.

      GC1612

    Correct Answer
    B. GC1622
    Explanation
    The caller is asking if they can change their plan so they can see a provider closer to them. The correct answer, GC1622, is likely the Good Cause code that allows for a change in plan due to limited provider options in the caller's area. This code would apply if the caller's current plan is not accepted by any providers near them, forcing them to travel over an hour away for care.

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  • 9. 

    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.

      GC17

    • C.

      GC9

    • D.

      GC1622

    Correct Answer
    C. GC9
    Explanation
    The caller is expressing their concern about their meal delivery company no longer accepting their plan. They mention that they like the company because they are always on time and make good food. Based on this information, it can be inferred that the caller values punctuality and quality of food. GC9, which focuses on "Quality of Service," would be the most appropriate Good Cause to address the caller's concerns and potentially offer a solution to change their plan to one that the company will accept.

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  • 10. 

    Caller is locked in and says: "My plan has changed my doctor seven times in the past year, so I haven't been able to really get comfortable with any of these providers. Can I change my plan? Which good Cause can you use?

    • A.

      GC1622

    • B.

      GC1620

    • C.

      GC17

    • D.

      GC1621

    Correct Answer
    B. GC1620
    Explanation
    The correct answer is GC1620. This is because GC1620 is the Good Cause code that allows a caller to change their plan due to frequent changes in their doctor. The caller states that their plan has changed their doctor seven times in the past year, which indicates a lack of continuity and comfort with their healthcare providers. Therefore, they would be eligible to use GC1620 to request a plan change.

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Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • May 16, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Nov 24, 2014
    Quiz Created by
    AHSFLTrainer
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