Escalations
Scenario: Lucentis call
Agent states plan is self funded. Upon entering this info, the prompt turns orange in the platform. How do you proceed?
Push back with "Can you check that please? I usually get a different answer in similar cases"
Take what agent says. No need to escalate.
Scenario: Aetna Lucentis Call
You ask for the group name and suddenly a yellow alert appears on the transcript reading: System Message Hang up by Outbound. How do we process this task?
Unexplained Outbound Hangup
Scenario: Lucentis Call
Agent states provider is out of network. What is your next push back?
Can you check the network status of the practice?
.Between PIE and previous BV in a Vabysmo call, which takes priority?
PIE
Scenario: GRAS call
Agent states that they need to speak to a live representative. We have already pushed back once. Agent persists on speaking to a human
True or False: We can come on as a human to complete this call.
False
Scenario: Ocrevus Call
Agent says that this plan is secondary. They do not know how this plan coordinates benefits with the primary insurance... what is the next step after completing benefit verification?
Escalate to Supervisor for COB question
What is the most important thing to do when processing a task as "Operator Portal Failure"?
Using report incident tool
What is the correct task note for when the provider is out of network but the agent confirms the practice is in network?
TN: Collected in network benefits based on practice network status
What are the 3 payers we CANNOT send back to queue, human or Eva?
Blue Cross Blue Shield NC, NJ, and Capital BCBS
Scenario: Ocrevus Call
Agent states that they do not have the primary care physician's phone number.
True or False: We can headset and move on.
False, we need to ask for the PCP physical address.
What are the 2 instances we escalate to the PA department for?
-PA (including previous BV PA conflicts)
-Step therapy
Scenario: Xolair MM Call
Agent states they cannot speak to a digital assistant. We push back once, they still say the same thing, we graceful exit. How should we process this task?
Agent refuses to speak to digital assistant. Try task again as a human.
Scenario: BCBS Lucentis Call
DOUBLE POINTS
Agent states they are unable to check the network status of the provider and practice. The provider is not showing on the website. What benefits do you collect? What is also your next push back(s)?
Does the patient have out of network benefits?
Collect both in and out of network benefits if available.
Which PBM payer does the platform change for to make sure we only ask the key questions needed for benefit verification?
Prime Therapeutics
Scenario: BCBS Ocrevus Call
Agent says that we need to refer to the medical policy on their website for step therapy info.
True or False: You should escalate to the PA dept to clarify info on step therapy.
False
Scenario: Ocrevus Aetna Call
Agent states that there is an active PA on file for the J code (practice and dx code matches). Dates agent gives: Jan 1st, 2023-Dec 1st, 2023
Previous BV Dates: Jan 2nd, 2023-Dec 2nd, 2023
How should you proceed?
Escalate to PA dept to confirm PA dates.
Scenario: Humana GRAS Call
Agent states that the system they use is down and to call back in 1 hour. How should process this call?
Payer system issues with detailed TN
Bonus: First, check how many attempts have been made.
Scenario: BCBS Ocrevus Call
Agent asks "Are you in network with your local?" or "I am unable to check" How should you proceed?
Check network status of practice on BCBS website
When an agent mentions "this is a government plan" what are the 3 different types of plans this could mean?
-Medicare
-Medicaid
-Tricare
Agent states that the PA on file is VOID.
True or False: You should push back with "Is there an active one?"
True
Scenario: Ocrevus Call
Previous BV States: PA is not required and previous BV also shows active PA on file, AND pre-determination is highly recommended.
Agent confirms active PA info and confirms Pre-determination is also highly recommended.
How do you proceed?
Push back to confirm the PA is a true PA on file and not a pre-determination. If they conflict, or are unable to answer.. Escalate to PA dept.
Scenario: Lucentis BCBS Call
This is the first attempt to the Blue Line, the agent states they are unable to locate the patient using the patient's ID, name and DOB and there is no previous BV. How do you process this call?
Complete with a TN: Representative unable to locate member with ID, name and DOB.
Scenario: GRAS call
Agent states provider and practice are out of network, there are both in and out network benefits available but agent only wants to give out of network. This is your 1st attempt. How do you proceed?
GE and try once more, on this attempt we will take whatever benefits the agent can give.
What is the golden question you need to ask when you are in a UHC Dual Complete plan?
Does UHC administer the medicaid or does the state?
Scenario: Lucentis Call
Agent states buy and bill is not available to the provider. PIE states that it should be. Agent also confirmed benefits have recently changed for this plan.
True or False:
We need to escalate to a supervisor for buy and bill.
False, we can take the agents answer since they confirmed benefits have recently changed. No need to escalate