Correct Dropdowns
Member is upset that she called in and phone was disconnected and no one called her back.
What would be the dropdowns for this scenario?
Reason > Customer Service
Sub Reason > Customer Service
The caller is upset bc > They did not receive call back as expected.
Member experienced a delay in receiving medication(s) due to pharmacy's action, and the member ran out of medication(s)
What kind of compliance is this?
QOC
Member is upset that he received a call from the doctors office changing his appointment while he was on the way to the appt.
What information is missing in this compliant reason
Doctors name, address and phone number. time and date of the appt and the reason for the appt.
Bonus!
Person calls in but is unable to HIPAA - Unable or Refusal to Verify
What can be discussed?
What must be authenticated when calling out to a member?
Member's First and Last name
Full Date of Birth (MM/DD/YYYY) with exception. If you added dob you are not wrong. If you did not add dob you are not wrong bc there is an exception.
Member called in complaining that he can't see his rewards online. It says, "try back it will update later"
What would be the dropdowns for this scenario?
Reason > Customer Service
Sub Reason > Technology
The caller is upset bc > They were experiencing issues while using the website.
Member is calling in stating her doctor put her on Ozempic but the plan will not pay and she needs her medication. What type of compliance is this?
CD
Member is upset that Dr Kendall 555 Truth Lane, Dallas Tex. 75216 sent her medication to the pharmacy but it was not covered and she really needs her meds.
What is the missing information?
Name of medication, dosage, strength. Part B or Part D
What Can Be Discussed After Authentication or Hippa verification?
name at least 3. If you name all 5 you made Bonus!
Basic Plan Information
Member Enrollment
Member Claims
Member Medical Information
When making an outbound call. Once member has identified himself. What disclaimer comes next?
This call may be recorded for quality and training purposes.
Member went to pay his utility bill at Walmart and found out that the utility company does not participate in the program.
What would be the dropdowns for this scenario?
Reason > OTC Healthy Food/Utilities
Sub Reason > OTC Healthy Food/Utilities
The caller is upset bc > The utility provider does not participate in the utility program
Member is upset that she had a 3 day stay in the hospital and when she needed someone to come to change her and her bed it was a long wait.
QOC
Member called in to get transportation to take her to the doctors office at 9am.
What is the missing information
Name of drop off location, date of arrival, reason for the visit,
Bonus, if you add will call for return or return information you bonus.
If caller needs to request OD for member to get a Wheelchair, (member is not on the phone) Can we proceed with the OD?
No. We would need members consent to move forward.
If, when you call out to the member and you ask, Am I speaking with (first name / last name) but they do not respond. What would be our next question?
Member is upset that she didn't receive her Ozempic from CVS bc it requires additional information.
What would be the dropdowns for this scenario?
Reason > Pharmacy
Sub Reason > Pharmacy Operation/Policies/Correspondence
The caller is upset bc > Other> No PA on file
Member called in stating she needs a new wheelchair. The chair that she has is 8 yrs old and is breaking down.
What type of compliance is this?
OD
Member called in stating her food order never arrived that she made online.
What is the missing information?
Date of order, order number, name of store, and confirm email.
If caller calls in on behalf of the member but is not showing a AR, POA or AOR. Can they 3 way call the member for us to get permission to add the caller?
No. A third party cannot conference the member and we cannot call any number provided by a third party.
When making an outbound to return a call to the member. But they do not answer. What information can you leave on the vm machine?
Please name at least 3
Message may include:
Your name, The first OR last name of the member
A call back number or instructions for calling back
Statement you are returning their call (if applicable
Member is upset that the driver took her home and she needed help getting out of the vehicle but the driver just sat there.
What would be the dropdowns for this scenario?
Reason > Transportation
Sub Reason > SafeRide
The caller is upset bc > The driver did not assist the member with getting in or out of vehicle.
Member called in upset bc he was scheduled for a 4-hour chair for dialysis treatment but receives less time due to transportation getting him there late.
what kind of compliant is this?
QOC
Member is upset that he had a housecalls appt but no one showed
Date of appt, Time of appt
Caller calls in stating there as been an emergency and they are needing benefit information. The caller is not on the acct as AR, POA or AOR. Can we help?
Yes. But they must authenticate Member First and last name and Date of birth.
Caller information First and last name Relationship to member (e.g., executor, trustee, guardian
They type of emergency
When making an outbound call to a member and a unidentified person says you have the wrong number.
What are the next steps?
Confirm the phone number matches the one in the member's account.
Apologize for the inconvenience.
Remove the incorrect phone number and replace with all nines (9).
Follow process within Outbound Inbound Call Team - Reporting or Updating a Wrong Phone Number for assistance.