Basic Terms
A federal law that outlines the rules and requirements plans must follow to provide health care insurance coverage for individuals and groups
What is HIPAA?
"I definitely understand your concern with receiving a bill you did not expect to be responsible for. I'd be happy to research the claim with you today and see if there is a patient responsibility applying."
Which service mentor Step or steps is this an example of?
Step 1. Acknowledgement, Step 2. Gain control with an "I can" statement
What is the NPS question we ask our members?
What is "On a scale of 0-10 how likely are you to recommend BCBS to a friend or collegue?"
DAILY DOUBLE!!!
BCBS uses two surveys to gather member feedback.
What are these two surveys?
What is Post Call Survey (PCS) and Member experience survey (MES)?
Allowable Charge: 150.00
Deductible: 1000.00 800.00 Used/1000.00
Coinsurance: 80/20
What will I pay?
Patient Responsibility: 150.00
The maximum amount a health plan will reimburse a doctor or hospital for a given service.
" Are there any other concerns I can address for you today?"
Which service mentor step or steps is this an example of?
What is step 8?
We categorize a members survey response as ________ when they issue a rating between 7-8. These ratings are left out of the NPS calculation.
What is Passive?
You are required to educate the member on this survey at the closing of every call, you must disconnect the call in ACE for the member to be connected to this survey
What survey is this?
What is Post call Survey (PCS)?
Allowable Charge: 5,748.00
Deductible: 1000.00 300.00 Used/1000.00
Coinsurance: 90/10
What will I pay?
Patient Responsibility: $1204.80
This is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copays and coinsurance, your health plan pays 100 percent of the costs of covered benefits
What is Out of Pocket Maximum (OPX)?
"I can email you the ID card or I can walk you through obtaining the ID from our website. Which of these options works best for you?"
Which service mentor step or steps is this an example of?
What is step 5. Offer a solution with options, step 6. gain acceptance?
What does the Acronym "NPS" stand for?
What is Net promoter score?
This survey take place 24-72 Hours after a call, statistical process determines survey release
What is member experience survey (MES)?
DAILY DOUBLE!!!
Allowable Charge: 716.24
Deductible: 500.00 150.00 Used/500.00
Coinsurance: 80/20
What will my insurance plan pay?
Plan Responsibility: 292.99
DAILY DOUBLE!!!
This applies when you are covered by two different health plans and helps avoid duplicate payments while ensuring the right payments are made by each plan
What is Coordination of Benefits?
"I have been on hold for 45 minutes just to get someone on the phone! All I need you to do is reset my password so I can login online, it shouldn't be this hard!"
Please respond using the Service mentor call strategy
Agent should respond using step 1&2
We categorize a members survey response as ________ when they issue a rating from 0-6.
What is Detractor?
You received 10 total surveys last month.
4 Promoters
2 Detractors
4 Passives
Using the NPS calculation what is your NPS score for the month?
What is 20?
Allowable Charge: 167.81
Deductible: 500.00 327.49 Used/ 500.00
Coinsurance: 70/30
What will I pay?
Patient Responsibility: 167.81
Services provided by a physician or other health care provider with a contractual agreement with the insurance company and covered at a higher benefit level
What is In Network?
DAILY DOUBLE!!!
You have assisted a member with their ID card request. You emailed a temporary card to the member and also requested a physical card to be mailed to their address.
Please provide an example of step 7 for this scenario
Example: So I was able to assist you with obtaining your temporary ID card today in your email. I also requested a physical card be sent to your address. You can expect to receive this card in 7-10 days.
DAILY DOUBLE!!!
This is the caculation used to determine NPS score
What is
Total Promoters - total detractors = Difference
Difference/ total number of surveys = Quotient
Quotient * 100 = NPS
To ensure proper MES survey distribution you must:
Document the _________ and select the correct _______ for the caller in ACE.
What is a phone number and relationship?
Allowable Charge: 9,854.21
Deductible: 1000.00 1000.00 Used/1000.00
Coinsurance: 80/20
What will my insurance plan pay?
Plan Responsibility: 7390.66