Disclaimer,
Downstream Impact
or Both
Downstream Impact
or Both
Member, Betty Smith puts her sister on the phone.
OBC Disclaimer must be read
"This call is being monitored and recorded for quality and training purposes"
Member calls in to ask if their cardiologist is in network.
MM has a PPO plan
* Check to make sure provider is INN @ location the mm is going to
* Advise MM of any OOP copay/coins for both INN & OON costs
* Advise mm if a referral is required or not
* If a referral is required, advise mm: referrals are required to see Spec, PCP can put up to 99 visits on the Referral. Referral remains valid for one year if the 1st visit is used within the 1st 90 days. if not used, referral will expire after 90 days and a new one will be required for any further visits
MM calls in and states: "I went to my primary care doctor appointment and waited in the waiting room for over an hour, no one came out to let us know the Dr was running behind, so anyway I left and now I missed my appointment, do you believe that, I waited for over an hour. In fact a few people walked out, not just me, everyone was upset."
* File grievance
* Empathize with the mm's feelings & incident
* Offer to call providers office and re-schedule the appointment for or with the member
Member requested a provider directory mailed to their home.
Both!
* Provider discliamer must be read
* Downstream impacts:
~ Advise mm the timeframe to expect to rcv the provider directory
~ Verify residential address on file
Memeber calls in to ask if their primary care doctor is in network.
Members plan is an HMO plan, PCP selection is required and Referrals are required.
* check if provider is in network at the location the mm will be seeing the provider.
* Provide mm copay and explain there is no OON coverage with this HMO plan, must use INN providers only
* Advise mm it is required to list their primary care doctor on their ID card, ask if it is ok to add this provider
* if PCP is added, advise mm they will rcv a new ID card in 8-10 days
Member calls in with an upset tone and states: "I was supposed to get my wheelchair yesterday, they told me that the wheelchair would be here and it still has not arrived yet. I planned my entire day around the wheelchair being delivered and its still not here, I am so annoyed, what am I supposed to do? "
* File Grievance
* Provide Empathy & Understanding
* Offer to call vendor for status of wheelchair delivery
MM calls in to file an expedited appeal due to rcving a letter denying their upcoming test.
KA: 2825
Disclaimer:
Aetna Medicare members have the right to request an expedited appeal should they feel that the standard 30-day turnaround time could jeopardize their health.
requesting an expedited appeal is not a guarantee that it will be processed as such. If the Medicare Appeals team does not find cause for this to be expedited, it can be updated to a standard Medicare appeal. If the appeal is changed to a standard appeal the member will have the right to file an expedited grievance.
Member calls in and states: "I had a recent procedure and my doctor is ordering me a nurse to come into my home to change my bandages, is this covered and how much will I have to pay for this?"
Educate the mm:
* Home health Care provided in the home setting must be ordered by a doctor or medical professional that works with a doctor and the services are deemed medically needed
* to be eligible for these servcices you must be unable to leave home without considerable effort or without the aid of another person or a device
* Part-time or intermittent skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week
* Custodial care (or non-medical home care) is a service that assists with daily living activities, these type of services are not covered
* Advise mm of copay using EOC or GPS
* Offer to locate INN HHC agencies for the mm
Member calls in and states: I have an appointment with my dermatologist next week, can you tell me how much my copayment will be?
Member has an HMO plan and you advise the member their copay is $20.00.
Take ownsership by asking for the name of the provider to make sure they are INN
* Educate the mm that their HMO plan only covers INN providers.
Checking to see if the mm's plan requires referrals -----> if so, more ownsership by explaiing how referrals work and offering to call the members Primary care Dr to advise that a referral is required for the members dermatologist appointment next week.
If you are transferring a member to OTCHS, what are the steps you take?
Both!
* Downstream Impact: Provide member with OTCH soultions ph # & website for future usage if needed
* OBC disclaimer is read to the rep you are transferring to (we own OTCHS but bc it is a non-internal company, we must read OBC disclaimer)
Member calls in and is asking why their payflex card has a balance left on it but it's not working. You find that the member has an Extra benefits card, the extra support wallet.
* Explain payflex has been discontinued
* Advise the mm has an EBC with an extra support wallet for the purchase of: Food, Personal Care Supplies, OTC, Utilities, Transportation
* Educate mm on: Allowance amt, monthly or quarterly, The Extra Supports Wallet covers the purchase of healthy food items and fresh produce. The card can only be used at network retailers.
* Provide website, Ph #, the locations listed in KA
* It cannot be used to purchase tobacco, alcohol, candy, soda or chips
* Can purchase by phone, online, retail
* If your purchase exceeds your available balance, you may use an alternative form of payment to pay for the remaining purchase balance.
* Provide all of the same info above for Personal Care supplies, OTC, Utilities, & Transportation (KA 4313)
Member calls in needing to set up a ride to their upcoming appointment. You provide full education on the benefit and the phone number for safe ride.
Offer to call safe ride and schedule the appointment with the member and safe ride together
Member calling in about an upcoming procedure. You educate the member that the procedure is covered under their out pt. benefit, provide the member their $185 copay for in network & $250 for out of network, advise no deductible applies, check and confirm their provider and location of procedure are both in network.
BOTH!
Discliamer: Provider dislciamer read bc you advised the provider and location are INN
Downstream Impact - Does this procedure require a prior authorization?
* check if procedure requires prior auth = true FCR
If this step is missed = the member becomes a repeat caller, asking if the procedure requires a prior authorization
Member calling in about an upcoming procedure. Member is asking about the coverage and cost of their procedure.
What is the full education required to provide to the member?
Educate the member on:
* procedure is covered under their ___ benefit
* provide any copay/coin/deductible that applies
* check to make sure the provider and location of procedure are both in network
* check if procedure requires prior authorization
* Check if referral is required
Member calling in about an upcoming procedure. You educate the member that the procedure is covered under their out pt. benefit, provide the member their $185 copay for in network & $250 for out of network, advise no deductible applies, check and confirm their provider and location of procedure are both in network, you find that this procedure requires prior authorization.
Ownership - Offer to call ordering provider to advise that a prior autorization is required for this procedure, provide the provider services ph #.