Escalations
Should you do an escalation as a human or Eva?
Human
True or false:
You can process a task as "Other".
Between PIE and previous BV in Ocrevus, which takes priority?
Previous BV
Scenario: Lucentis call
Agent states provider is Out of Network, how do we proceed? What is the next push back?
Can you check the network status of the practice?
What is your best friend when searching for information in a document?
EX (GNE Q and A, SOP,.. etc)
Control F
TRUE or FALSE
We escalate for the question "Does the specialist office copay apply regardless of whether the office visit is billed or not?" when the agent is unsure.
True
What should you do when processing a task as Operator Portal Failure?
Use report incident tool.
Bonus: Also record console data to show Eng what issues you are having.
Scenario: You are in a Vabysmo call.
Which is priority? PIE or Previous BV?
PIE
Scenario: Lucentis BCBS Call
Agent states they are unable to check network status of the provider.
Provider is listed on the BCBS website. What type of benefits do you collect?
In Network
Bonus point: Add TN: Payer portal confirmed that the provider is in network
What resource/document do you check to make sure we are calling the right phone number?
Identifying insurances doc
What are the 3 instances in which we escalate to a supervisor for?
-COB question
-Buy and Bill
-SOV question (Does the specialist office copay apply regardless of whether an office visit is billed or not?)
Incomplete: Need to call a different number
Scenario: Plan we are calling on is secondary. Which is priority, PIE or Previous BV?
Previous BV
Scenario: Agent says provider is in network at a different location. How should we proceed?
Bonus point: Collect the in network address the agent has.
What resource do you check to see if you can override an agent's answer for Lucentis?
Lucentis and Vabysmo Escalate and Override Chart
Found in the GNE QA
True or False:
PIE goes out the window when doing an ESCALATION.
True
Agent states that are unable to speak to/ unable to provide benefits to Eva.
What should we process as?
Agent refused to speak to AI voice. Restart call as human.
Scenario: You are in Lucentis call
Agent says there is a PA on file and Step Therapy is not required.
Previous BV states ST is not required
PIE states it ST IS required. Which is priority?
PIE
-EXTRA Point: second step would be to check Escalate and override chart.
Scenario: GRAS
Agent confirms provider AND practice are OON. The agent states no OON benefits are available and is refusing to give In network benefits. How should you proceed?
Collect the reference number, GE, and try for another agent once more.
What resource/doc should you check if you are having trouble manually driving a call to an agent?
IVR Tips and Tricks
Scenario: GRAS call
Previous BV states NO PA required or on file.
Agent states there is an active PA on file, confirms all info (dates, auth number, J code and Dx match, and provider matches)
Do we need to escalate?
No, if there is active PA on file no need to escalate for PA or previous BV.
After how many attempts can we process a task as "Payer Unreachable" before we can send to the Review team to fail?
2
Scenario: You are in a Xolair major medical call. There is no previous BV or PIE.
Which takes priority?
Whatever the agent says.
Scenario: Ocrevus BCBS Call
Agent states they are unable to check the network status of the practice. Practice appears on the BCBS website at a different address, how do we proceed?
Input In network at a different address, but collect both in and out of network benefits.
Also input whatever address BCBS website states.
The UHC Medicare Advantage Dx Code H35 Chart is used to determine if ____ is required or not.
Step Therapy