Call Flow/ Handling
HIPPA
Order Placement/New RX
WIs/JA/CIF
Misc.
100

Per WI What are some tip on how to avoid Non- interaction/silent or mute time? 

  • Content ID : TSRC-PROD-066076

    Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfer

Tips to avoid Non-Interaction (NI) time:

  • Walk the caller through what you are doing and keep the member engaged.
  • Use positive words and phrases, such as: “I definitely want to give you an accurate answer, I’m going to research this.”
  • Avoid muting the call/headset. Mute should only be used temporarily to prevent members from hearing sneezing/coughing, etcetera.
100

If you are speaking with a third party, and the fully authenticated member has given permission (over the phone) to discuss/share their medical/personal information and/or make changes with the third-party, you may treat the third-party caller as an authorized representative for this call only TRUE OR FALSE

Content ID : CMS-2-028920

HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS

TRUE 


100

A provider calls regrading a New RX request, They would like to get a new prescription in. How can you help? 

Content ID : TSRC-PROD-054208

Compass - Obtaining a New Prescription (Rx) for the Member (New Rx Request)

Warm transfer to FastStart for prescribers at 1-800-378-5697 




100

What WI will you find information on AI calls? 

Content ID : TSRC-PROD-059690

Incoming Artificial Intelligence (AI) Calls to Customer Care (Automated Calls, Robocall, or Computer Calls)

100

Time Limits for Filing a Grievance

What WI will you find this information in? 

60 days

CMS regulations state:

“An enrollee may file a grievance with the Part D plan sponsor either orally or in writing no later than 60 days after the event or incident that precipitates the grievance.”

Content ID : TSRC-PROD-066741

Compass MED D - When to File a Grievance in Compass

200

When returning to a caller, after placing them on a hold for a warm transfer what should you do/say?

HINT: Step 12

What WI will you find this information? 

Hint: Warm

Thank the caller for holding, apologize for the delay and introduce the caller to the receiving party. Wait for the receiving party to take over the call before disconnecting.

Content ID : TSRC-PROD-066076

Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfer

200

True or False Third party callers can change account phone numbers, add or remove current payment methods and request a override 

What WI will you will find this information?

False

No changes to the account can be made by the caller.

Examples of account-level changes include the changing vital details on an account:

  • Phone number
  • Address (includes temporary address)
  • Email address
  • Assist with Caremark.com
  • Add or remove current payment methods.
  • Assist with any medication the caller did not first tell you the name/Rx number.
  • Place Hold, Cancel, Discontinue an order (Prescription (Rx)).
  • Request Plan Benefit Override (PBO).

Please refer to: 

Content ID : CMS-2-028920

HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS

200

Provide the TAT for when the order is expected to ship

Content ID : TSRC-PROD-054262

Compass - Mail Rx Refill/Renewal (Order Placement)


  • Prescription refills with no issues (not expired or out of refills) ship within two business days after order is placed/received.
  • New prescriptions ship within 5 business days after order is placed/received.
200

Who handles Prior Authorizations for client code X6027? 

Where did you find this information?

Caremark

Content ID : CMS-PRD1-078376

CIF Migrated to Compass-Empire Commercial (NYSHIP)

200

Who can start or check the status of a coverage determination or a redetermination?

What WI will you find this information in? 

Before beginning the process or checking the status of a Coverage Determination or Redetermination, the CCRs MUST verify they are speaking to one of the following individuals:

  • Beneficiary
  • Authenticated SHIP Counselor
  • Physician or other Prescriber (includes representative of a prescriber's office or a representative of the prescriber)
  • Power of Attorney (POA) or Appointed Representative (AOR)
    • Legal Documentation MUST be viewable in Compass or FACETS to continue with the caller's request.
  • Pharmacy
    • The pharmacy can check the status of a Coverage Determination or Redetermination.


Content ID : TSRC-PROD-064997Compass MED D - CCR - Coverage Determinations and Redeterminations (Appeals)

300

What are the steps for receiving an internal (Aetna or CVS caller)  warm conference/ Transfer call?

Content ID : TSRC-PROD-066076

Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfer

  1. Verify and document:
  • Conferencing/Transferring representatives first name and initial of last name.
  • Conferencing/Transferring “from” department name.
     
  1. Ask if the call has been fully authenticated.
  • Note: If the transferring agent does not confirm the caller has been fully authenticated, treat it as not authenticated.
300

What should you do if the person you are speaking with changes? 


Remember, if at any point in the call the person you are speaking WITH or ABOUT changes, STOP and re-authenticate.


Content ID : CMS-2-028920

HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS

 

300

When placing a refill, what details would you need to recap on the order? 

Content ID : TSRC-PROD-054262

Compass - Mail Rx Refill/Renewal (Order Placement)

Please allow me to recap your request. Today we are filling:

  • <Member’s name>
  • <Medication name, strength, dosage form>
  • <# Available Fills>
  • <Quantity for day supply>
300

A member calls in with Client code X24CM (MHBP) and asked for the status update for an appeal, who handles appeals? 

MHBP Handles Appeals:

MHBP
PO Box 981106
El Paso, TX 79998-1106

Provider can call 1-800-638-1440 and fax 1-866-669-5614. 


300

What are the 4 key habits?


1. Provide a ‘yes I can help’ statement/reassurance statement.

2. Ask Days’ Supply of the medication the member has on hand.  

3. Access and utilize the appropriate CIF/Work Instructions. 

4. Summarize/recap reason for call, including ensuring all concerns have been addressed. 

Content ID : TSRC-PROD-020070

Service Excellence - Customer Experience Guidelines and Expectations

400

1.What authenticators are needed for a Non-CTI/IVR Authenticated or Partially Authenticated person Calling for Self and or Power of Attorney? 

2.What WI will you find this information? 

Hint: Call Flow

Note: Caller must provide full name of member, if only first name is given prompt the caller for the last name.

1. Are you calling for yourself today?

2. Thank you. What is the date of birth please?

3. To validate the account, can you confirm the Member ID?

If unable to verify Member ID, use Secondary Authenticators:

Prescription Name

Prescription Number

MED D Only: MBI

 4. Thank you, what is the Zip Code?

If unable to verify Zip Code, ask for Plan Sponsor as Secondary Authenticator.

Content ID : CMS-PRD1-095822

Universal Medicare D - Consultative Call Flow (CCF) Process



400

True or False 

PHI/PII can be left on voice mail


FALSE

 PHI/PII cannot be left on voice mail. You can state the first name of the member then leave a number for the member to call back as appropriate. 


PHI cannot be left on voice mail. Leave a number for the pharmacy, prescriber, or member to call back as appropriate.


Content ID : CMS-2-028920

HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS


Content ID : CMS-2-024665

Inbound or Outbound Call - Quality Recording Disclaimer


400

What is step seven for a prescription refill? 

Content ID : TSRC-PROD-054262

Compass - Mail Rx Refill/Renewal (Order Placement)

Confirm that the member has more than 5 days’ supply of each medication on hand.



 

400

A member with a the client code of X5522 (Carefirst Med D EGWP), called in needing to order a new refill, you assisted the member and recapped the call. You notice an orange banner stating "Caller is eligible for post call survey" in compass. Where can you find the process for this client on the after-call survey?

Client information Section of the CIF

After-Call Surveys:

Members can be automatically transferred to an after-call survey for an opportunity to give their feedback. *Special Note: For calls, you will need to release the call at the conclusion of the conversation rather than letting the member hang up at the conclusion of the call. Please remind the member of the after-call survey: ”Please remain on the line for quick satisfaction survey regarding your call today, your feedback is very much appreciated.”

Content ID : TSRC-PROD-046916

CareFirst BlueCross BlueShield Group Advantage (PPO)

400

Provide me an example of a resolution question typically stated after recapping/summarizing the call? 

Did I cover all your reasons for contacting us today?

 

  • This final question offers additional assistance and gives the caller another opportunity to potentially ask questions or solve other issues while they have us on the phone.
  • We should first provide a call summary before asking if the caller’s concern has been resolved.
  • If the resolution question is provided too soon, the member may assume the call is complete and hang up prematurely, leaving potential concerns/questions unaddressed.
  • Call summary ensures that all inquiries have been fully resolved, reinforcing a positive service experience and preventing misunderstandings and/or future calls.


Content ID : CMS-PRD1-095822

Universal Care - Consultative Call Flow (CCF) Process

500

An account wellness check is when you view the member’s account for potential issues. 

What are some places you may view to check for these potential issues ?

How often do you perform account wellness checks? 

What WI will you find this information? 

HINT: Call Flow

  • Review, and update as needed, the following:
    • Member’s address, phone number (including type: Mobile or landline), and email address.
    • Mobile and email contact details capture or confirm, and verify or update the Messaging Preferences (email, text, and phone).
    • Perform a full Account Wellness review, including viewing the members’ account for potential issues.
  • Depending on the reason for the call, also review:
    • High Priority Comments/Stop See Messages/Compass Alerts
    • View recent activity to determine if the caller is a repeat caller
    • Prescription history
    • PBO/PA history
    • Accumulations
    • Other relevant sections based on the call context

 Content ID : CMS-PRD1-095822

Universal Medicare D - Consultative Call Flow (CCF) Process

500

When WARM transferring to an external organization including but not limited to benefit offices and government offices (such as Medicare) when are you allowed to release PHI/PII information? 

Content ID : CMS-2-028920

HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS

If you are speaking with the member directly, or the POA, and they give you permission, you may proactively release the member’s PHI/PII.

 "Jon, thank you for your patience. I am absolutely going to get you to the right place. To make sure they understand what we need and are ready to help you, can I share your personal and medical information with them?"

500

If the prescription is the member's last refill, what options would be available to the member to obtain a new prescription? 

Content ID : TSRC-PROD-054262

Compass - Mail Rx Refill/Renewal (Order Placement)


Proceed with the Refill/Renewal even if this refill is the Last Fill available or if the Rx will expire before the member’s next refill. Advise the caller of the following options to obtain a new prescription:

  • Request a provider to call or fax a new prescription into Caremark.
  • Request Customer Care to contact the provider.
  • Request a new written prescription from the provider and mail it in. Refer to Compass - New Rx Request Scenario Guide (Popups, Warnings, and Written Prescription) (054354).
  • Check Client Program Offering for the Auto Refill Program.
500

A member calls in and you need assistance from a Senior Team member in entering an override per the CIF. What WI would you utilize to help you initiate this process?

Content ID : TSRC-PROD-077869

Universal Compass - Initiating an Assist (Slack Users)


500

A Member called in with the client code of X24CM   and asked for a price estimate on Wegovy. You run a test claim that confirmed a Reject 75. The account shows no prior authorization on file or initiated. After Brining up the CIF, What would you do?


Initiate ePA.

Content ID : TSRC-PROD-055814

Compass - Initiating an ePA Request


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