Hip Hipaa Hooray
Updating paperless status or Veteran status does not require HIPAA verification, but updating this type of personal record does.
What is contact info
Digital Guides can change a member's PCP or mail out disenrollment forms, but these two formal benefit disputes cannot be accepted or initiated via Portal Chat.
What are Appeals and Organizational Determinations
To show they are taking ownership of an incoming inquiry, a Digital Guide must use one of these. This helps keep things running smoothly and in order as received.
What is an emoji
To personalize a digital interaction, guides should check this AI-generated profile feature to learn about the member's background and preferences.
What is the "Get to Know MEMBER" section
This is one way we Connect
These 4 team members all live in FL - 5 if you include me ;)
Andy, Debbie, Jasmin, and Mackjeannie
You can share generic claim statuses like "received" or "pending" without verification, but you MUST verify HIPAA before sharing this type of claim outcome.
What is approved/denied (or specific PA/claim details)
When a member reports a medical or mental health emergency via Portal Chat, you must create a case for this clinical program.
What is Care OnDemand?
Bonus: In a Care OnDemand emergency case note where a member needs immediate first responders, you must use STAT. Needs 911 [or 988] in your documentation.
Providing this many different resolutions prior to arriving at the correct one will cause an interaction to be marked "No" for efficiency.
What is two or more (if unsure always ask clarifying questions before providing answer)
Catching subtle tone shifts—like a member expressing defeat or frustration over a delayed process—is key to identifying dissatisfaction and fulfilling this core requirement under the Listen pillar. Other examples include ALL CAPS or multiple exclamation points.
What is identifying/filing a Grievance
This is one way we Listen
These two distinct components must both be confirmed by the member to complete a full HIPAA verification via SMS.
What are member identity and member consent
When a member expresses general dissatisfaction, guides should immediately file this in Orinoco.
What is a Grievance?
Bonus: we do not need member permission, but should advise them we’re filing it
Select this issue type when a guide has the right KB Card pulled up but needs help translating the information into actionable steps.
What is Resource Interpretation
When a member's issue involves complex needs, bringing others to the table might mean creating a case to loop in these specialized teams.
What is Care OnDemand, Community Guide, or applicable Clinical team
This is one way we Solve
If HIPAA is needed and either verification box is unverified, you should use this macro to attempt to move the conversation to portal chat.
Question: What is .phi
If a member states they plan to contact Medicare, a lawyer, the media, or the BBB, you must post in #member-helpline and tag this team, in addition to filing the grievance.
What is @CTM_Team
Select this issue type when a guide is unsure of the proper sequence of steps or isn't sure if a situation is a Grievance vs. an Appeal.
What is Process & Workflow Guidance
Reviewing past interaction notes to ask about a member's recent doctor visit or ongoing issue is an example of doing this in a digital chat.
What is Connect (aka picking up breadcrumbs)
While scheduling a Devoted Medical Primary Care appointment via SMS requires no verification, discussing these specific medical details does.
What are diagnoses, treatment plans, lab results, or appointment details outside of specialty names?
When supporting a disruptive member who requires additional assistance, create a Request / Supervisor Transfer case and post in this channel while tagging this team
What is #sms-discuss and @obguidesupervisor
This issue type should be selected when a guide cannot locate the correct article or documentation because they aren't using optimal keywords or questions in GSK tool.
What is Resource Navigation
Looking ahead when a member asks about a specialist means also verifying if the specialist requires a referral or prior authorization, which is an example of doing this.
What is Solve? Look 3 steps ahead and solve that problem too