CALLERS
An individual enrolled in a health insurance plan, including the primary policyholder and dependents.
Member
The fixed amount a member must pay before the insurance company begins sharing the cost of healthcare services.
Deductible
A document that lists covered prescription drugs, grouped into tiers that determine member cost.
Formulary
A federal law enacted in 1996 that protects sensitive patient health information and sets standards for privacy, security, and confidentiality.
Health Insurance Portability and Accountability Act
This call type involves helping a member request a replacement ID card and may take 7–10 business days for delivery.
Member ID Request
A licensed healthcare professional such as a doctor, nurse, or therapist who provides specialized medical services.
Professional provider
The most a member pays for covered healthcare services within a plan year before insurance covers 100%.
Out-of-pocket maximum
The official plan contract that explains covered services, exclusions, and limitations in detail.
Evidence of Coverage
One key reason why HIPAA matters is that it helps establish this between patients and healthcare organizations.
Trust
This is required before processing requests such as member ID or materials to ensure the caller’s identity is verified.
HIPAA verification
A legal document that allows someone to make decisions or act on behalf of another person.
Power of Attorney
A summary that explains how a claim was processed, including what was covered, denied, or applied to member responsibility.
Explanation of Benefits (EOB)
The best tool to use when answering cost-related questions such as copays, coinsurance, and deductibles.
Schedule of Benefits
Any health-related information that can identify a person, combining identity and health data.
Protected Health Information
This call type includes checking enrollment status, reviewing disclaimers, and confirming prescription coverage.
Benefits and Eligibility
A person who is professionally qualified to prepare and dispense medications.
Pharmacist
A long-term illness that requires ongoing treatment, such as diabetes or hypertension
Chronic condition
A standardized document that provides a high-level summary of benefits and is used to compare plans.
Summary of Benefits and Coverage
The minimum number of identifiers required to properly verify a member before disclosing any information.
Two identifiers
This type of request may include items like a handbook, formulary, provider directory, or welcome packet.
Material Request
A caller who is contacting someone within the same organization or company.
Internal caller
Standardized codes used to describe diagnoses, procedures, and services to ensure consistent communication and accurate claims processing.
Medical codes
A key action agents must follow to minimize errors and escalations when assisting members.
Provide accurate and consistent plan-based information
A strict action agents must take if a caller fails verification during a call.
Do not disclose any PHI
his call type requires asking for member preference, confirming address, and reviewing the Primary Care Provider on file.
Provider Search Inquiry