Knowledge check

A healthcare program representative assisting a caller over the phone with supportive information and resources in a friendly office environment.

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

53 Questions13 MinutesCreated by HelpingHeart32

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)

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.

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

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

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.

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

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

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:

Which format communication will the patient receive from the program representative to remind them of their daily pill? ( Check all the apply)

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

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.

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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