HIPAA/Authentication
The four authenticators for a NOT CTI/IVR call
First and last name
Date of birth
Member ID
Zip Code
The first step after you have identified a grievance
Check the CIF to determine who handles the grievance type for the plan
What you must do if you run a test claim and receive this reject code: Prior Authorization (Reject 75)
Peoplesafe users: Create a CD&A RM Task
Compass users: Manually submit a Med D CD&A Support Task as needed.
The first step in placing a refill order
Ask the member how many days’ supply of medication they have on hand
The amount of seconds you have to answer the call
3 seconds
The correct way to answer a call for a plan that does NOT have a specific greeting (i.e. FEP MPDP or Indiana University Health plans)
Thank you for calling. My name is ______. Who am I speaking with?
Beneficiary
Power of Attorney (POA) or legal representative (guardian) for the beneficiary
Appointed Representative (AOR) (includes a Provider/Prescriber)
SHIP counselor
Informal authorized 3rd party
The first thing you should do when completing a coverage determination
Refer to the appropriate CIF to determine who handles Coverage Determinations for the plan
What you are required to say to the member after providing their copay amount
The copay disclaimer: "Please keep in mind that the amount due for your order may vary from this quote upon processing"
The four secondary authenticators
Prescription name
Prescription number
MBI
Plan sponsor
The question you should ask every caller during authentication (unless it is an internal transfer that has already been fully authenticated)
Are you calling for yourself today?
The time limits for filing a grievance
60 Days!!
“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.”
Therefore, if the elapsed time between the date of the event (or occurrence) and the date of reporting the Grievance is greater than 60 days, a Grievance should NOT be opened.
Note: If the event date is open to interpretation, choose the most recent reasonable date.
Up to 72 hours from date/time of receipt of valid request, but exception requests may be up to 408 hours (17 days) if a statement of medical necessity is needed from the Prescriber.
The TAT statement for a RX that has refills remaining and is not expired
You can expect your order to ship from our pharmacy within two business days. Monday through Friday are considered business days, although mail order is open every day
The only required question to ask on an internal transfer call
Has the caller been fully authenticated?
The question you should ask only to third parties
Is the beneficiary aware that you are calling for them today?
For an open/new grievance, the next step after documenting the grievance in PeopleSafe with detailed notes
Contact the Senior Escalation Line to provide the reasoning to file a Grievance in PeopleSafe to obtain permission
Some of the words/phrases that indicate a request should be expedited instead of standard
The 4 pieces of information that a third party must provide in order to be able to place a refill order
Medication name
Delivery address
Member phone number
Last 4 digits of CC# or just say "use default card"
The exact statement you should say to a caller that has called 3 or more times within 7 consecutive days for the same issue or who has a history of calling for the same issue that remains unresolved
Please allow me to transfer you to our Senior Team who can provide further support. May I place you on a brief hold?”
The person or persons that can update an address/telephone number/email address
The member
Legal representative (POA, legal guardian, legal conservator)
After checking the CIF to ensure Caremark handles the grievance, and after making sure that the caller is authorized to file a grievance, your next step should be
Always check PeopleSafe for existing Grievances!!
The mandatory step that is required to be performed for all coverage determinations to confirm accuracy
Repeat the entire request back to the caller
What you must do if a member has a $0 copay, no payment method on file, and the "save order" tab is NOT present
Submit a manual refill request RM Task
The 3 parts of call documentation