Benefit and Coverage Education
Member calls in and expresses concern regarding the high cost of Ozempic Medication. What are the Steps we take?
Investigate the purpose of the GLP1 medication. If for weight loss advise of GLP Bridge program. All other reasons provide precertification process, and resources such as benelynk and rfl.
When you update member pcp to a new office what steps should you take?
Advise member about new ID card, arrival timeframe, and address verification for both member and pcp.
If member doctor has moved and the member ask for the new location. What steps would you take?
representatives should confirm the request, call the doctors office, gather any needed details, and research the provider information before discussing alternative providers.
Who is Benelynk?
A member expresses financial hardship and may benefit from screening for programs that could help lower healthcare-related costs. They should be transferred to this team.
If a member spouse joins the call what steps do you take?
Advise of call recording disclaimer and document who you are speaking to.
Member calls in about Hearing benefit. What information should be provided?
Benefit is administrated through NationsHearing, NationsHearing phone number, the allowance amount, and frequency of hearing exam and fitting/evaluation.
What is the timeframe ANOC and new benefits can be discussed?
Anytime after 10/01
When a member answers the phone how long do you have to respond?
What is a transfer to Benelynk?
This transfer is appropriate when a member no longer qualifies for Medicaid, is facing disenrollment from their D-SNP plan, and may need assistance identifying financial aid programs or other coverage options.
When documenting in SCP what should be included?
Member is losing Medicaid eligibility and is enrolled in a DSNP plan. What advise should be given?
Educate the member on any applicable Special Enrollment Periods, expected disenrollment timeframes, and the need to enroll in another Medicare plan to avoid a potential gap in coverage. Ask the member if they have renewed or not yet if they have not transfer member to care team or benelynk.
Taking a look at this plan. What is the cost share you would quote the member for amlodipine for 2026 and 2027 if the member goes to Walgreens for the prescription?
2026 - $2 for 30 days
2027 - $5 for 30 days
What must you do on all calls to reiterate what was stated on the calls and when do you do this?
You summarize and it can be done at end of call or throughout the call.
Who is Telesales? Do we warm or cold transfer member?
After educating a member about the Annual Enrollment Period (AEP), this is the department you should transfer them to if they would like to review and compare available plan options for next year. We warm transfer unless directed to cold transfer
Member has an Upcoming Plan Change Alert. When you address it with member they say they haven't received there ANOC what is you next steps?
Offer to go over the ANOC with the member. Also, advise it can be found online and if applicable offer to mail to member.
Member is unhappy with there plan changes for next year and would like another plan. What would you Advise the member?
Provide AEP timeframe 10/15-12/07 and offer to warm transfer to telesales
What is Complete Member Education?
Providing accurate, thorough, and proactive information so the member understands their benefits, coverage changes, available resources, required actions, and any applicable timeframes.
What is active listening?
A member is upset about a recent plan change and begins explaining multiple concerns. Instead of interrupting or immediately offering a solution, this communication technique involves fully listening, acknowledging their concerns, and confirming your understanding before taking action.
What is a specific hold-time estimate for the member?
(3-5 minutes) While completing a warm transfer, an advocate needs additional time to reach the receiving team. Before placing the member on hold, the advocate should obtain permission, explain the purpose of the hold, and provide this key detail.
What is the NBA alert?
system alerts that are available in gps, advocates should review and address them, including upcoming plan changes, in-home assessment opportunity, and VBC elgibility.