Disclaimer,
Downstream Impact
or Both
Downstream Impact
or Both
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
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