Department Roles
Receives, processes and makes decisions on service requests from members and providers.
What is the UM Department?
Member is upset that her PCA is always late.
What is a Grievance/Complaint?
Member's Name, Date of Birth (DOB), Full Address, Phone Number, Medicaid ID #, CPHL Legacy ID #, Social Security # (SSN), Medicare Beneficiary Identifier (MBI)?
What are HIPAA Verifiers?
I assess a Prospect using a Uniformed Assessment System to determine the services they qualify for, after a CFEEC Assessment has been completed.
Who is the Intake Nurse (RN)?
All inbound/outbound call interactions are documented here.
What is an Activity Log?
Member calls requesting to speak to her Care Manager to submit a new request for Home Delivered Meals.
What is Customer Care- Care Manager Services?
Receives and handles post-service reimbursement requests received via inbound phone call.
Who is Member Satisfaction?
Before filing for a State Fair Hearing, members must first request this.
What is an Internal Appeal?
Member: Hi, I need to find a foot doctor in my area.
MSR: Sure, I am familiar with your podiatry benefits. I can help you locate a par provider and assist with scheduling an appointment.
May I have the member's full name and date of birth, please?
What is Acknowledging the Caller's Concern and Offering Action?
Inbound call is received by MSR at 6:37 PM from a member's daughter reporting that the member fell and is now admitted to St. Joseph's Hospital.
MSR warm transfers the call to __________ for further assistance.
Who is the On-Call CM?
All service request decisions are found here.
What is the Authorizations Tab?
Member: I need a member handbook, seemed to have misplaced it in my old apartment.
MSR fully verifies HIPAA, verify the member's mailing address (updates address if applicable) and advises the Member Handbook should be received in 7-10 business days.
MSR documents the request in an Activity Log (status left ________), Activity Type: __________, Activity Detail: ________________ and sends the request via email to ______________________.
What is "Complete", "Inbound Call", "Customer Care- Plan Materials Request, "CPHL Member Materials"?
MSR documents the request in an Activity Log (status left Complete), Activity Type: Inbound Call, Activity Detail: Customer Care- Plan Materials Request and sends the request via email to CPHL Member Materials.
Provides consistent oversight, coordination and support to members and their families in accessing MLTC plan-covered services.
Who is a Care Manager?
To request a State Fair Hearing, members would call these people.
What is the Office of Temporary & Disability Assistance (OTDA)?
Who is the New York State Department of Health (NYS DOH)?
Inbound call is received by an MSR: Member received her incontinence supplies today and realized her diapers are too big. Member requests a change in size from Large (L) to Medium (M).
MSR educates that the request will be processed and the next shipment will include size Medium diapers.
Note: Member's Care Manager belongs to Care Solutions.
Who is the Clincal Ops Coordinator?
Central location for an enrollee's Demographics, File Status, Eligibility, Line of Business (LOB), PCP information, Surplus, Assigned Care Manager, Emergency Contacts and ID #s.
What is the Member File Tab?
Member calls to disenroll from his MLTC Plan because he is moving to New Jersey in 2 months.
MSR: Documents details in an Activity Log (status left __________), creates a _____________, then sends an FYI email to the assigned CM.
What is "Pending", "Disenrollment Event"?
MSR: Documents details in an Activity Log (status left Pending), creates a Disenrollment Event, then sends an FYI email to the assigned CM.
Processes prospect's enrollment prior to submitting to the State, confirms eligibility to placement in one of CPHL's plans, processes plan-to-plan transfers, processes prospect permanent address updates and creates CaseTrakker files after a referral is received.
A disagreement with CPHL's grievance resolution- submitted in writing within 60 business days of the grievance decision.
What is a Grievance Appeal?
This member is currently enrolled in our Managed Long Term Care Plan, effective 1/01/2020. CPHL is primary for routine dental care and our dental vendor is HealthPlex. The member's CPHL ID number is 0000-12345.
Call reference number is Jane Doe, 3/04/2020 2:34 PM.
What is Member Eligibility?
Assists CPHL members with Medicaid recertification.
Who is FHS Consultants?
Central location for any Vacations and admissions to Skilled Nursing Facilities (SNF), Hospitals, Rehabilitation and Emergency Room (ER) Visits.
What is the Interruption of Care Tab?
Prospect calls to _______ their enrollment into the CPHL MLTC Plan prior to their UAS Assessment.
MSR documents all relevant details in an Activity Log (status left ______), Activity Type: _______, Activity Detail: _________).
What is "Withdraw", "Pending", "Cancellation/Withdrawal"?
MSR documents all relevant details in an Activity Log (status left Pending), Activity Type: Inbound Call, Activity Detail: Cancellation/Withdrawal).
This extension is used to help members with transportation when the vendor is listed CPHL Ambulance.
What is ext. 3785?
A group that provides free, confidential assistance on any service offered by CPHL.
Who is the Independent Consumer Advocacy Network (ICAN)?
Janet's monthly income is $1,500 and the monthly income limit set by the Department of Social Services (LDSS) is $800. Janet must pay $700 to Medicaid each month to continue to be eligible for Medicaid and MLTC services.
What is a Surplus or Spend-down?
Assists CPHL prospects with Medicaid certification.
Who is Senior Planning Services (SPS)?
Inbound call received by MSR from a member who had a missed call.
Member states the voicemail was in regards to a decision on a service request. You locate the documentation for this type of call and warm transfer the member to the representative for further assistance.
What is a Verbal Auth Notification (found in the Authorizations Tab)
MSR receives an inbound call from a prospect on the May 18th, requesting to accept the POC offered on May 15th.
MSR documents all relevant details in an Activity Log (status left ______), Assigned to: ______, Activity Type: _______, Activity Detail: ________ and sends an email to _________________.
What is "Pending", "Intake RN who completed the UAS Assessment", "Inbound Call", "Request Call Back", "CPHL Intake RN Supervisors"?
MSR documents all relevant details in an Activity Log (status left Pending), Assigned to: Intake RN who completed the UAS Assessment, Activity Type: Inbound Call, Activity Detail: Request Call Back and sends an email to CPHL Intake RN Supervisors.