QOC, INQUIRY OR STANDARD GRIEVANCE
Member is upset that he has been calling his doctor’s office for a week and there has been no Response
What is a QOC
This SOP is used to select the category that you should file your grievance under
What is the Greivance Categorization Job Aid/SOP (via greivance handling SOP)
Advocates can expedite determinations and appeals as a courtesy (without expression of medical necessity) for members.
What is FALSE
Did you know that you can use this SOP when a member is dissatisfied with their Dentures.
What is Dental Coverage- Dental Returns
What information must we indicate if the member has accepted or declined
What is The QIO Information
Member is upset that the receptionist at the doctor's office was rude
What is a Standard Grievance
Member stated they are not happy that their plan requires them to pay $25 for a specialist visit.
What is Plan - Plan Benefits
All Compliance submissions must be summitted same day, at least 2 hours after the navigator has spoken with the caller
What is FALSE
Did you know that you can ask questions here and receive additional compliance assistance and information
What is The Compliance Yammer Page
These 5 things MUST be included in the greivance section of EVERY greivance filed.
What is the 5W's
Member is unhappy with a Dr’s recommended treatment plan
What is a QOC
Member is upset that she had to wait over 10 minutes before speaking to a rep when the UHC Navigator transferred her to the renew rewards dept.
What is Non-UHC External Dept./Complaint About Call Time / Hold Time / Transfers
DAILY DOUBLE: When attaching a note to an already submitted grievance, the agent must click on the Intent labeled Compliance, Appeals and Grievances under recent cases.
What is "False" Answer: The Actual Compliance
Did you know that you should refer to this SOP if their is a denial for a compound medication
What is the Compound Medications SOP
Every greivance Resolution MUST begin with this
What is.... apologized and advised that UHC takes these grievances very seriously.
Member is upset with correct information provided by UHC Representative
What is a Standard Grievance
Member is dissatisfied with the rude interaction that she had with a Housecalls representative
What is Call Center- Advocate/Interaction
If a DSNP advocate was documenting a member’s grievance about another UHC employee, the DSNP advocate us expected to either send an e-mail to the employee’s supervisor or enter the details on a SharePoint
WHAT is FALSE-
Did you know that whenever a compliance has timed out in Maestro, you would need to click here to re-open the SAME greivance and re-enter the information lost
What is Dashboard (click on Home and then dashboard)
Document as Part C or Part D: Member is upset that they placed an order for Losartan with OptumRx and it hasn't been received yet. Member is on an MAPD plan
What is Part C
"Hi, I am calling to get a new ID card. My PCP office makes me so upset when they tell me that I have to bring in my ID Card. Shouldn't they have that on file already?
What is an Inquiry
Member is upset, she has spoken with UHC customer service 8 times to request a plan formulary. Most recently, She has contacted UHC 16 days ago but the member still has not received the formulary.
What is Call Center- Advocate Interaction
When handling B vs D determination calls, a trial claim should be processed prior to initiation a determination.
What is TRUE
Did you know that a member would follow this process if they have OON benefits, however the OON provider is attempting to charge the member up front
What is member would have to file a pre-service Appeal (Agent will not submit a COC or a MIOD for this scenario).
DAILY DOUBLE- Agent will complete this step if corrections are needed after a compliance has been submitted.
What is "Attach a Note"