Knowledge check
Knowledge Verification Quiz
Test your understanding of best practices in caller identity verification and resource allocation for program representatives. This quiz covers essential information essential for effective communication in healthcare support.
- Identify key information needed from callers
- Understand the process of warm transfers
- Review denial types and appeals process
What is the following information that a program representative will try to obtain from each caller to verify their identity?
Caller type, First and Last name, and State or location from which the call is being made.
Caller type, first and last name, and Social Security Number.
Date of Birth, First and Last name, State or location from which the call is being made, and Social Security Number.
If the caller is the patient/guardian, Program representatives will also attempt to obtain? (check all that apply)
Primary contact first and last name
Primary contact phone number
Work phone number (if applicable)
Best time to contact
Primary language
All of the above
What are the minimum requirements that are needed to be documented in the database?
Caller name, Caller state, either mailing address or phone number and reason for call.
Caller name, DOB, Caller state, either mailing address, or phone number and reason for call.
Caller name, Caller state, date of birth, either mailing addresses or phone number and reason for call.
Program Representatives will triage caller to appropriate resources using a Warm Transfer method approach?
True
False
What is considered a Warm Transfer?
Live agent is available to further assist
Program Representative that is transferring the call introduce the caller
Prior to transfer the Program Representative will state the purpose of the call with providing all relevant information
Program Representative allows the caller to repeat all information that was previously provided.
Program Representatives provide a range of support excluding?
Benefit Investigations/Eligibility
Alternate Coverage Research
How To Submit an Off Label Request
Research for Prior Authorization Process
General Payer Policy Research
Billing and Coding Support
Appeals Process Handling
Program Representatives provide a range of support excluding?
Reimbursement Support
Care Coordination Support
Emotional Crisis Support
For reimbursement support a program representative provides all the following services: Alternate Coverage Research, How to Submit an Off Label Request, Research for Prior Authorization Process, General Payer Policy Research, Billing and Coding Support, Appeals Process Handling, and Benefit Investigations/Eligibility.
True
False
Which Program Representative offers patient education materials, this information is to potentially provide disease state education and information on all approved indications of the product.
Reimbursement Support
Care Coordination Support
Which of the following information is not required to complete a Benefit Investigation?
Patient Name, Contact Information (Address, Zip, and Phone number), and DOB
Insurance Information
Referring Physician
Treating Physician Name and Specialty
Treating Physician’s tax documentation (1040, 1040A, 1040X, etc)
Treating Physician Contact Information (Address, Site Name, Phone and Fax Numbers)
Treating Physician’s Tax ID
Treating Physician’s Provider # with Insurance Carrier and NPI
Diagnosis
What Information is needed to complete the Cost Share Profile?
Deductible and Amount Met
Coinsurance and/or Copay
Out of Pocket Maximum and Amount Met
Annual/Lifetime Benefit Maximum and Amount met (If listed for plan)
All the above
VOB can be faxed to a patient.
True
False
What method can a patient receive a VOB?
Mail
Fax
Email
Verbal
If a Prior Authorization is required and on file; what information is obtained?
Prior Authorization Number, Prior Authorization Start and End Dates, Prior Authorization Renewal Process
Prior Authorization Number, Prior Authorization End Dates, Prior Authorization Renewal Process
There is no further information that is needed to be obtained.
How often should an Administrative Denial Appeal be followed up on?
At a minimum of every 14 days until the claim has been resolved.
At a minimum of every 7 days until the claim has been resolved.
At a minimum of every 3 days until the claim has been resolved.
Which type of denial is claim denied for a clinical reason such as medical necessity or use for an off-label diagnosis?
Diagnosis Denial
Clinical Denial
Administrative Denial
Which type of denial is a claim denied for an administrative error such as incorrect coding or missing information related to coding?
Diagnosis Denial
Clinical Denial
Administrative Denial
What are the Prior Authorization services that we can provide?
Prior Authorization Research and form preparation
We don’t provide services for Prior Authorization
If Prior Authorization is on file what information program representative needs to obtain? (check all that apply)
Prior Authorization number
Prior Authorization coverage and results
Prior Authorization requirements (such as LMN, sample exception letter, Prior authorization number or other claims documentation needs)
Prior Authorization start and end dates
What is a Formulary Exception?
Prior Authorization and Formulary Exception are the same
Formulary Exception is for Pharmacy benefits only
Formulary Exception is the process of obtaining approval for coverage for a medication that is not covered under the patient’s plan.
Does the Program Representative seek to obtain formulary exception on behalf of a physician?
True
False
Who the Program Representative will call to provide detailed status on a Formulary Exception?
The physician office only
The insurance company
The physician and patient
The patient only
Information to be obtained during the appeal process includes the following?
Payer Name
Policy Number
Date(s) of Service
Date claim was denied
Reason for denial
All of the above
Program Representative must determine if appeals include elements of Administrative Denial and/or Clinical Denial, and take appropriate follow-up steps in accordance with the applicable SOPs.
True
False
Program Representative will schedule follow up to-do based on anticipated processing time, at least every 10 business days until claim is resolved.
True
False
When the Program Representative will research a general payer policies and procedures?
When the medication is off-label
When we receive a request form to research for general information not patient-specific verification
When the medication is not covered under patient’s plan
Program Representatives will research the requests for non-patient- specific billing and coding questions by:
Utilizing available in-house resources
Calling the payer or using the Payer’s website
All of the above
Program Representatives will not aid with issues related to documenting individual patient’s medical needs.
True
False
The phone-based reminder is considered ________________ after one attempt or when the Program Representative speaks with the requestor.
Pending
Complete
Incomplete
After the initial call has been made, when will a Program Representative follow up with the patient to provide affordability information?
7 Days
3 Days
1 Day
Once a patient has opted- in to receive Support Services, the Program Representative can offer which of the following services:
One time and Ongoing fulfillment of educational materials
Online resources available
Daily Emails
A and B
A, B and C
Which format communication will the patient receive from the program representative to remind them of their daily pill? ( Check all the apply)
Voice
Text
Email
Pharmacy does it
All the above
Which product the patients pharmacy is not contacted?
CVM
Immunology
Neither
For which product does this apply to: If the patient had not refilled their prescriptions, Programs Representative will follow-up with pharmacy prior patients scheduled refill date and will notify the patients' health care provider?
Remicade
Stelara
Simponi Ari
For ____________ reminder calls, the patients will be required to modify the reminder schedule on the portal if changes are required.
Automated
Non-automated
Program Representatives will follow up with the ___________ prior to each refill to remind them to contact their pharmacy to refill their medication.
Patient
Site
Nurse
Program Representative will verify that the patient has ___________ to this service. Results of the patient opt-in will be documented in the _________.
Opt-in, program database
Opt-out, program database
Questions, on paper and sent via fax to the site
Call script are applicable to ___________ only regarding enrolling a patient into the Janssen Care Path Savings Programs.
California
United States
Puerto Rico
During call, after designated the call guide, the program rep will ensure the following
If applicable, that the patient is in possession of or will be receiving a non-expired cost support or instant savings card
That the patient has not previously enrolled in the same program
That the patient has not already exhausted the program’s benefit
That the patient is qualified to receive the program’s benefits based on its guidelines and confirmation from the program’s third-party administrator
That the patient agrees to all terms and conditions required by the program
That the patient was not previously opted out of the program
All the above
Program representative will assist with a live OP enrollment into the savings program if the patient is a _____________ .
SIRTURO
All calls
Not able to log into patient portal
Upon Successful/Completed Sirturo Enrollment, the Program Representative will send the patient’s ______________ via email to the TCMA Program Manager.
First and last name
First and last name, date of birth, and address
Case number
Through designated Call Guides/Call Scripts, the Program Representative will enroll patients through the following process:
The Program Representative will select the product “Edurant” and complete enrollment in the Support Center Database
The Program Representative will verbally provide the patient with the following card information:
The Program Representative will manually opt out patients from all communication in the Support Center Database: Saving Card ID#, Rx Group #, Rx Bin #
All the above
The Program Representative will add the following note to the patient’s case in the Support Center Database:
Sirturo Savings Program Enrollment Complete
Patient has been opted out of all program communications
Email sent to Program Manager with case number
All above
Before providing any service requested by a caregiver, the Program Representative must identify:
The caller requesting the service
The patient for whom the caller is the requesting service
The proper documentation is on file within the program database which allows the services to be offered
All of the above
The patient may request removal of any documented caregiver at any time.
True
False
If the reporter of the adverse event decides not to provide any additional details and they do not want to be contacted, then the AE/PQC does not need to be reported.
TRUE
FALSE
How should a representative respond to a patient inquiry that asks how we use their Protected Health Information (PHI)?
Your personal information is used by Janssen Pharmaceuticals for program enrollment and administration; in compliance with the privacy policy.
We are not liable due to we are a third party.
We only share it to the manufacture.
A Limitation of Service (LOS) is requested by the __________.
Patient
Site
Janssen
What are the 3 distinct benefits that the program representative may verify for a prescribing provider from the payer?
Assignment of Benefits
Buy & Bill
Pharmacy
All of the above
What is the difference between a Universal Business Associate Agreement (BAA) and a Customized BAA?
The Universal BAA is our Standard Business Associate Agreement. We do not accept Customized BAA from any of our sites.
There is no such thing as a Universal BAA. Our Customized BAA is the one that is offered which the site has made changes or customized the document to meet their specific needs. When a Customized BAA is received, it must be sent to IBM for review and approval.
The Universal BAA is our Standard Business Associate Agreement. A Customized BAA is one in which the site has made changes or customized the document to meet their specific needs. When a Customized BAA is received, it must be sent to IBM for review and approval.
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