What are the four authenticators?
Member's first name and Last Name, member's DOB, Member ID, ZIP CODE
True of False: we must answer the call within 3 seconds
True! Per LOB guidelines Answer within three seconds
Step one for a prescription refill
Ask the member how many days’ supply of medication they have on hand.
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.
After you determine that the caller is expressing dissatisfaction what do you do?
How do you answer CMS Test Call?
Always answer “Yes I can” when asked if you can assist.
What is Secondary Authenticators ?
True or false: If speaking with A 3rd party, they must provide the last four digits of the credit card and expiration date or say “use default card” to complete the order, along with the member address and phone number.
TRUE!
Standard request decision
Decision within 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.
who is authorized to file a Grievance?
Before beginning the Grievance process, CCRs MUST verify they are speaking to the beneficiary, SHIP Counselor, an Appointed Representative, or the Power of Attorney.
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:
Please refer to:
Content ID : CMS-2-028920
HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS
3 or more calls within seven consecutive days for the same issue Or you recognize from the Notes or View Activity has a history of calling on the same issue that remains unresolved regardless of the time period…
what is a procedural Senior team transfer?
"Please allow me to transfer you to our Senior Team who can provide further support. May I place you on a brief hold?”
Warm transfer to the Senior Team
Reminder: Log the call as a Transfer.
Add Notes: Include one of the following keywords: Repeat, Multiple, or Unresolved Issue.
Please keep in mind that the amount due for your order may vary from this quote upon processing.
What is the price disclaimer?
who can start or check the status of a coverage determination or a redetermination?
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:
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.
True or false We can provided the member ID number to members ONLY
False
Do not provide the effective dates and/or the member ID* for the member’s account.
what needs to be pulled up on every call?
The Source
Utilize theSource and PeopleSafe/Compass on every call. For each situation you should review the work instruction specific to the scenario at hand. If UNABLE to resolve the issue and you have utilized all resources (team chat, supervisor, team SME), inform the member that you would like to reach out to the Senior Team for assistance and to ensure an accurate resolution.
What is the TAT for when the order is expected to ship?
True or false:
Only file a First Call Resolution Grievance for plan design issues or for issues with the Coverage Determination process.
TRUE
True or False
If another grievance is submitted for the same category that is closed we should file a new one
TRUE!
What is the next step after obtaining the member's First and Last name for a authenticated caller?
Ask "Are you calling for yourself today"
Please refer to:
Content ID : CMS-2-004568
Universal Medicare D - Caller Authentication
After resolving the issue: Provide solutions, alternatives, and additional options
What do you do next?
Hint: 3 answers
1.RECAP!
Recap the call.
2. Closing with the appropriate closing
"Thank you for calling. It’s been a pleasure speaking with you, have a great day!"
3. Documenting the Call:
What all do you need to recap in the Refill Snapshot screen including the member's name.
Hint:
Content ID : CMS-2-004628 Prescription (Rx) Refill/Renewal (Order Placement)
When do you transfer to senior team in regards to coverage determinations?
When a Grievance is handled by the Client, what verbiage should be used since a Grievance cannot be offered?
Inform the beneficiary the issue is handled by the Client and warm transfer the call so the issue can be resolved.