Call Handling
This technique helps the MCA identify the member’s primary need and uncover additional concerns.
What is active listening?
This type of question invites the member to explain what is happening in their own words and should generally begin the discovery process.
What is an open-ended question?
This document explains how an insurance plan processed a claim; it is not the same as a provider bill.
What is an Explanation of Benefits, or EOB?
This service helps members find high-quality in-network providers with personalized support.
What is a Concierge Referral?
This is the main reason detailed notes are important after a member interaction.
What is ensuring continuity of service for the next team member?
The standard hold-time estimate is approximately this long.
What are 3–5 minutes?
These questions help the MCA uncover needs that are related to, but not directly stated in, the member’s initial reason for calling.
What are probing questions for latent needs?
Before opening a Claims Advocacy case, an MCA should review these sources to understand the member’s concern.
What are the Claims Dashboard, claim details, and EOB?
This service connects members with experts to review complex medical cases and provide guidance.
What is an Expert Medical Opinion, or EMO?
Notes should clearly capture these four things: the member’s need, actions taken, referrals, and this.
What are next steps?
After listening to the member, the MCA should do this to confirm understanding.
What is restate the member’s concern?
Before offering a benefit or service, the MCA should first do this to understand whether it is relevant to the member.
What is ask discovery questions?
These are examples of concerns that may be appropriate for Claims Advocacy.
What are billing errors, denied claims, or issues involving the provider or insurance company?
This program provides personalized support and coordination for members with acute or chronic care needs.
What is Care and Case Management, or CCM?
These four details should be included in a member interaction note to support clear follow-up and continuity of service.
What are the member’s need, actions taken, referrals, and next steps?
When discussing coverage, MCAs should proactively review these to help prevent billing surprises.
What are accumulators?
An HVR should be personalized to this rather than delivered as a generic list of services or an elevator pitch.
What is the member’s primary or discovered latent need?
When researching multiple claims, an MCA should ask for these details to identify the correct claim.
What are the date of service, provider, visit or procedure details, and other information that distinguishes one claim from another?
When opening a Concierge Referral, MCAs should gather provider, appointment, and contact preferences through these case tasks.
What is the Concierge Referral intake questionnaire?
This should be included when a case is created to resolve the member’s concern.
What is the case number or Care App link?
When discussing coverage, the MCA should proactively share this information—including the member’s copay, deductible, coinsurance, and out-of-pocket maximum—to help prevent billing surprises.
What is comprehensive cost-sharing information?
A member mentions an upcoming surgery and uncertainty about the treatment plan. This benefit may be relevant if probing confirms the member wants another clinical perspective.
What is an Expert Medical Opinion?
The purpose of documenting a Claims Advocacy interaction is to provide this to the next team member.
What is a complete history of the member’s concern, research completed, actions taken, and next steps?
A member facing treatment uncertainty, an upcoming surgery, or questions about a diagnosis may be a candidate for these two clinical referrals.
What are EMO and CCM?
This type of documentation can cause the member to repeat information and can make follow-up difficult.
What is missing or incomplete documentation?