Types of Grievances
Member is upset that she cant buy ice cream with her OTC benefits
Verbal Grievance
member stated that Dr. Miranda Bailey at Seattle Grace Hospital shouted at her and slammed the door in her face she was very rude to the member
Customer Service
Advocates can expedite determinations and appeals as a courtesy (without expression of medical necessity) for members.
FALSE
Did you know that you can use this SOP when a member is dissatisfied with their Dentures.
What is Dental Coverage- Dental Returns
What information must we indicate if the member has accepted or declined (QOC)
What is The QIO Information
member thinks it is not fair that some people have copays and others do not
HINT: member does not mention being upset, or frustrated
inquiry
the member stated she called in to pay her utility bill but became frustrated because she did not understand the representative because of his accent so she hung up and did not get to pay her utility bill
Customer Service
All Compliance submissions must be summitted at least 2 hours after the navigator has spoken with the caller
FALSE
Did you know that you can ask questions here and receive additional compliance assistance and information
What is The Compliance Yammer Page
These 5 things MUST be included in the grievance section of EVERY grievance filed.
What is the 5W's
complaints occur when services received by a member from a medical provider / facility or pharmacy are inadequate or substandard in quality.
Quality of Care
member stated this is the third time she has tried to call but every time she entered her member ID the IVR did not recognize it and this is very upsetting to the member
Technology
the member stated the driver was late picking her up to take her home from her office visit is a Verbal Grievance
true
Did you know that you should refer to this SOP if their is a denial for a compound medication
What is the Compound Medications SOP
Every grievance Resolution MUST begin with this
What is.... apologized and advised that UHC takes these grievances very seriously.
Member is upset that her medication Methotrexate for her Rheumatoid Arthritis is not covered
Coverage Determination
the member stated she called in and as soon as she was able to speak to someone the call disconnected and this is very annoying and frustrating to her
Technology
when submitting a grievance about another UHC employee make sure to include their full name and MSID
FALSE
Did you know that whenever a compliance has timed out in Maestro, you would need to click here to re-open the SAME greivance and re-enter the information lost
What is Dashboard (click on Home and then dashboard)
Document as Part C or Part D: Member is upset that they placed an order for Losartan with OptumRx and it hasn't been received yet. Member is on an MAPD plan
What is Part C
Member has been diagnosed with MS and needs a wheelchair.
MIOD
the member stated laughs and says "you all need better hold music, it reminds me of elevator music"
no need to file a grievance there is no complaint
this is correct documentation
Dr. L. Munster
1313 Mockingbird Lane
Hollywood TX 78345
False make sure to include the doctors full name address and phone number
Did you know that a member would follow this process if they have OON benefits, however the OON provider is attempting to charge the member up front
What is member would have to file a pre-service Appeal (Agent will not submit a COC or a MIOD for this scenario).
DAILY DOUBLE- Agent will complete this step if corrections are needed after a compliance has been submitted.
What is "Attach a Note"