Pavani Uppala

⮚This is the process of dealing with requests received from provider or member or
member rep regarding the coverage of Prescription Drugs. Coverage might be for
Post Service or Pre-service. We have many levels in Part D |.e. Pre-processing

⮚Intake, Setup, Pharmacist & finally coordinator level which fall under level 4 process

⮚Appeals are when you are dissatisfied with the decision the plan has made about a
coverage determination review. An appeal is a formal way of asking us to review and
change a coverage determination we have made

⮚A Grievance is a complaint or dispute, other than one involving an organization
determination expressing dissatisfaction with any aspect of the operations, activities,
or behavior of a Medicare health plan, or its providers. A grievance can be filed
verbally or in writing within 60 days of the prompting event or incident causing the
grievance. You may file an Expedited Grievance in the event you disagree with us
extending the process timeframe for an Organization Determination. A decision will
be made within 24 hours

⮚A Coverage Determination is the first decision made by Simply Healthcare Plans
about your benefits, including whether a drug is covered, whether you have met the
requirements to get a requested drug, how much you pay for a drug, and whether to
make an exception to a plan rule when you request it

⮚Coordinator is the process where we have to work on the decisions given by
pharmacist such as overturn, uphold, partial overturn, withdrawal

⮚|Itis the 4th level of process where in we need to audit the updated information which
was done by the previous level of process

⮚Coordinator process is a final decision maker to provide the conclusion for provider or
member disputes. And finally sending the letter regarding the conclusion to provider
and member with in a TAT (7 Days). Reviewing Appeal and closing the case within a
TAT of 7 days to make payment to the appropriate member or provider.

• Producers Services Agent Change Team Coordinator.
• Change of agents on the policies according to the request.
• Creating Beneficiary for Deceased agent and Commissions Redirecting to Beneficiary.
• Exercised in Streamlining the Process by Providing the Inputs for Quality.
• Manages work flow and responding to the emails within 2 hours of SLA.