2018 Fl Smmc Complaint Quiz
This quiz assesses handling of complaints in the Florida Statewide Medicaid Managed Care (SMMC) program, focusing on coverage issues, enrollment problems, and service adequacy.
- 1.
A caller states, “I want to file a complaint. This plan won’t give me any information about my coverage, and I’ve spoken to several different people. What’s the point of being on this plan if I don’t know how I’m covered?” What is the correct allegation for this complaint?
- A.
I need help enrolling/disenrolling or changing plans
- B.
I need help getting medical or dental care
- C.
I need help with getting information about Medicaid or my Medicaid Plan
- D.
None of these options describes my issue (with supervisor approval)
Correct Answer
C. I need help with getting information about Medicaid or my Medicaid PlanExplanation
The correct allegation for this complaint is "I need help with getting information about Medicaid or my Medicaid Plan." The caller is expressing frustration and dissatisfaction with not receiving any information about their coverage despite being on the plan. They are seeking assistance in understanding how they are covered under their Medicaid plan.Rate this question:
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- 2.
A caller states, “I just got off the phone with DCF and they claim to have updated my new address last week. Now you’re telling me it’s still not updated? How am I supposed to get a plan for my new area if my address won’t update? I want to file a complaint.” What is the correct allegation for this complaint?
- A.
I need help with getting information about Medicaid or my Medicaid Plan
- B.
I need help with having my personal information updated/corrected on Medicaid or plan record
- C.
I need help enrolling/disenrolling or changing plans
- D.
None of these options describes my issue (with supervisor approval)
Correct Answer
B. I need help with having my personal information updated/corrected on Medicaid or plan recordExplanation
The correct allegation for this complaint is that the caller needs help with having their personal information updated/corrected on their Medicaid or plan record. This is evident from the caller's statement that they were told their address was updated but it still hasn't been, and their concern about not being able to get a plan for their new area if the address is not updated.Rate this question:
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- 3.
A caller states, “This plan you all put me on is not providing enough therapy. According to my therapist none of the plans you have are offering the coverage I need. I want to file a complaint!” What is the correct allegation for this complaint?
- A.
I need help enrolling/disenrolling or changing plans
- B.
I need help with getting information about Medicaid or my Medicaid Plan
- C.
I need help getting medical or dental care
- D.
None of these options describes my issue (with supervisor approval)
Correct Answer
C. I need help getting medical or dental careExplanation
The caller is complaining about not receiving enough therapy and the therapist confirming that none of the plans provide the necessary coverage. This indicates that the caller's complaint is related to not receiving adequate medical or dental care.Rate this question:
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- 4.
A caller states, “I’m going to need to file a complaint. I only missed my Open Enrollment by a few days because I accidentally threw that letter away. Now you’re telling me I can’t change until next year because I don’t have a “Good Cause” reason? That’s ridiculous!” What is the correct allegation for this complaint?
- A.
I need help getting medical or dental care
- B.
I need help with having my personal information updated/corrected on Medicaid or plan record
- C.
I need help enrolling/disenrolling or changing plans
- D.
None of these options describes my issue (with supervisor approval)
Correct Answer
C. I need help enrolling/disenrolling or changing plansExplanation
The correct allegation for this complaint is "I need help enrolling/disenrolling or changing plans." The caller is expressing frustration with not being able to change their enrollment after missing the Open Enrollment deadline. They believe it is unfair that they are unable to make changes until the next year without a "Good Cause" reason. Therefore, they are seeking assistance with enrolling, disenrolling, or changing their plans.Rate this question:
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- 5.
A caller with an active TPL 11 on file states, “That Medicare coverage hasn’t been active for a while now. I already spoke with TPL and they advised me to get it removed so I can enroll. Can you help me?” What is the correct allegation for this complaint?
- A.
I need help with having my personal information updated/corrected on Medicaid or plan record
- B.
I need help enrolling/disenrolling or changing plans
- C.
I need help getting medical or dental care
- D.
None of these options describes my issue (with supervisor approval)
Correct Answer
A. I need help with having my personal information updated/corrected on Medicaid or plan recordExplanation
The caller is stating that their Medicare coverage has not been active for a while and that they have already spoken with TPL (Third Party Liability) who advised them to get it removed so they can enroll. Therefore, the correct allegation for this complaint would be "I need help with having my personal information updated/corrected on Medicaid or plan record." This suggests that the caller is seeking assistance in updating or correcting their personal information related to their Medicaid or plan record.Rate this question:
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- 6.
A caller states, “I need to get surgery after my car accident and the plan won’t cover it! I’ve processed a plan change into a plan that will, but I can’t wait that long to have this surgery, and you guys won’t make the plan change effective sooner! I need to file a complaint!” What is the correct allegation for this complaint?
- A.
I need help getting medical or dental care
- B.
I need help enrolling/disenrolling or changing plans
- C.
I need help with getting information about Medicaid or my Medicaid Plan
- D.
None of these options describes my issue (with supervisor approval)
Correct Answer
A. I need help getting medical or dental careExplanation
The caller is complaining about not being able to get surgery covered by their current plan and not being able to make the plan change effective sooner. This indicates that they are in need of help with getting medical or dental care, which aligns with the correct allegation for this complaint.Rate this question:
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- 7.
Scenario: John Doe is complaining that his son Louis Doe is not getting the amount of therapy he needs. When calling, John provided us with his own ID, and Louis is on a different case. Which of the following picture examples shows the correct behalf category process to use for this scenario?
- A.
Choose Recipient and select John Doe’s Member Checkbox because he is the one filing the complaint.
- B.
Choose Recipient and Search for Louis because he is on a different case than his father.
- C.
Choose Provider and search for the therapist Louis sees because the complaint is regarding Louis not getting the therapy he needs.
- D.
Choose General Population and enter Louis Doe’s name in the New Affected Party Field so his name can be added to the complaint.
Correct Answer
B. Choose Recipient and Search for Louis because he is on a different case than his father.Explanation
The correct answer is to choose Recipient and search for Louis because he is on a different case than his father. This is the appropriate process because John Doe is filing the complaint on behalf of his son, Louis Doe. Since Louis is on a different case, it is necessary to select him as the recipient in order to address the issue regarding his therapy.Rate this question:
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- 8.
Scenario: Lillian Fischer is calling to complain that her grandson, Rupert Fischer’s plan is unable to be changed. Lillian does not have Medicaid, but she had Rupert’s ID and was able to verify into his case. Which of the following picture examples shows the correct behalf category process to use for this scenario?
- A.
Choose Recipient and search for Lillian Fischer’s ID since she is the one filing the complaint.
- B.
Choose General Population and enter Lillian Fischer’s name in the New Affected Party Textbox so you can add her to the case.
- C.
Choose Provider and search for Rupert’s primary care doctor so he can be added to the complaint.
- D.
Choose Recipient and check Rupert Fischer’s member checkbox because she is complaining on behalf of her grandson and he is on the case.
Correct Answer
D. Choose Recipient and check Rupert Fischer’s member checkbox because she is complaining on behalf of her grandson and he is on the case. -
- 9.
The Affected Individual is...
- A.
The person or persons the caller is complaining against.
- B.
The person or persons being affected by the issue or problem.
- C.
The person or persons that constitute a Third Party Liability.
- D.
The person or persons that are the Target Party.
Correct Answer
B. The person or persons being affected by the issue or problem.Explanation
The affected individual refers to the person or persons who are experiencing the consequences or negative effects of a particular issue or problem. They are the ones directly impacted by the situation and may require assistance or resolution to alleviate their difficulties.Rate this question:
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- 10.
Which of the following statements is true?
- A.
All documentation submitted in HealthTrack is public record.
- B.
Media, government officials and/or court may view documentation submitted through HealthTrack.
- C.
Choice Counseling agents should always proof-read all of their notes for spelling errors, incorrect punctuation, and grammar.
- D.
All of the above.
Correct Answer
D. All of the above.Explanation
The correct answer is "All of the above." This means that all three statements mentioned in the question are true. The first statement states that all documentation submitted in HealthTrack is public record. The second statement mentions that media, government officials, and/or court may view the documentation submitted through HealthTrack. The third statement suggests that Choice Counseling agents should always proof-read their notes for spelling errors, incorrect punctuation, and grammar. Therefore, all three statements are true.Rate this question:
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- 11.
Before closing the call, Rosita tells the agent that she wants to cancel the complaint she is filing against her specialist. How should the agent proceed?
- A.
Cancel the complaint by clicking cancel on the bottom left corner or the “X” button at the top right corner of the Complaint Wizard.
- B.
Encourage Rosita to file the complaint.
- C.
Complete the complaint without Rosita's authorization.
- D.
Submit a request to have a Supervisor call back and further investigate the issue.
Correct Answer
A. Cancel the complaint by clicking cancel on the bottom left corner or the “X” button at the top right corner of the Complaint Wizard.Explanation
The agent should proceed by canceling the complaint as requested by Rosita. This can be done by clicking cancel on the bottom left corner or the "X" button at the top right corner of the Complaint Wizard. It is important to respect Rosita's decision and not proceed with filing the complaint against her specialist.Rate this question:
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- 12.
To remove HIV/AIDS, SMI, or Freedom Health special conditions from a recipient’s case, the agent should:
- A.
File a complaint in HealthTrack to remove the condition.
- B.
Submit a Special Condition Request in HealthTrack to remove the condition.
- C.
Submit a task to a supervisor and request the removal.
- D.
Contact the SNU and request they remove the condition.
Correct Answer
B. Submit a Special Condition Request in HealthTrack to remove the condition.Explanation
To remove HIV/AIDS, SMI, or Freedom Health special conditions from a recipient's case, the agent should submit a Special Condition Request in HealthTrack to remove the condition. This implies that the agent needs to follow the proper procedure within the HealthTrack system to request the removal of the special condition. This could involve providing necessary documentation or justification for the removal. Contacting the SNU or filing a complaint may not be the appropriate course of action in this case.Rate this question:
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- 13.
Tommy filed a complaint against Molina Healthcare of Florida and asks the agent for a complaint number. How should the agent proceed?
- A.
Inform Tommy that agents are not allowed to disclose the complaint number and he will be notified by mail with a resolution to his complaint.
- B.
Give the complaint number to Tommy.
- C.
Escalate Tommy’s call to a supervisor because only supervisors may provide the complaint number.
- D.
Advise Tommy that he needs to contact AHCA Medicaid Helpline to obtain the complaint number.
Correct Answer
B. Give the complaint number to Tommy.Explanation
The agent should give the complaint number to Tommy.Rate this question:
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- 14.
Megan Ross is calling to follow up on a complaint she filed against her health plan. The agent sees in the case history in HealthTrack that the complaint status is 'In Progress' but there is no further information on the complaint's status. Megan is adamant about obtaining more information about her issue. Where should the agent refer Megan for further assistance?
- A.
Escalate to a Supervisor
- B.
Refer to DCF/SSA/DOEA
- C.
Refer to the Health Plan
- D.
Refer to The AHCA Medicaid Helpline
Correct Answer
D. Refer to The AHCA Medicaid HelplineExplanation
The agent should refer Megan to The AHCA Medicaid Helpline for further assistance because they specialize in handling Medicaid-related issues and can provide more information about her complaint.Rate this question:
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- 15.
Julie Andrews just finished filing a complaint because the plan has not been providing her any information regarding who her son’s Primary Care Provider is. She wants to know if the state will fix the issue. What can we tell Julie?
- A.
Advise Julie she will need to contact the plan in 24-48 hours to see if the state has addressed the issue.
- B.
Inform Julie that we cannot guarantee the outcome of the complaint and refer to AHCA with the Complaint number for additional questions.
- C.
Tell Julie that the state will handle the issue and get the plan to give her the information she needs.
- D.
Offer to process a plan change so that she can get a better plan that will treat her properly.
Correct Answer
B. Inform Julie that we cannot guarantee the outcome of the complaint and refer to AHCA with the Complaint number for additional questions.Explanation
We cannot guarantee the outcome of the complaint and should refer Julie to AHCA with the complaint number for additional questions. This answer acknowledges that the state may or may not be able to fix the issue and advises Julie to seek further assistance from AHCA, indicating that they may have more information or resources to help her.Rate this question:
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Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.
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Current Version
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Mar 21, 2023Quiz Edited by
ProProfs Editorial Team -
Aug 06, 2018Quiz Created by
AHSFLTrainer
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