Grievance Systems
This system houses all of our grievance and appeals cases received, and where notes and letters are written.
What is iCare Path?
This department is the one that initiates and sends over majority of our grievances.
What is Customer Service?
This is the best place to verify who customer service was talking to when a grievance was filed.
What is the top of the grievance ticket?
This is the site used when we need to send something for transportation, dental, hearing, vision, Quest/Labcorp cases.
What is the NAS/Vendor sharepoint site?
This is the system we use to research plan benefits and costs.
What is Sensentia?
What system would we use to research if a member's plan materials were sent to them?
This department works with us to ensure that member's accurately received their Part C (supplemental) plan benefits?
If a third party filed a grievance on behalf of the member, this is the only way that the grievance would be valid without an AOR/POA/EOE or phone call to the member.
What is if the grievance indicates that the member was present for call and approves the grievance details at the bottom of the ticket?
When a member states that the agent that enrolled them into the plan misinformed them about their plan benefits/coverage, we would route it here.
What is Archer/CIU site for agent allegations?
This plan material is mailed to all members prior to the Annual Enrollment Period, to allow the ability to review the next year's benefits and switch plans, if desired.
In order to see a member's spendables account, such as transaction history or card information, you would use this system
What is Solutran PSP portal?
What is Appeals?
This is the only authorization document that is valid if a member is no longer living.
What is an Executor of Estate (EOE)?
This is how we submit an appeal if needed.
What is the appeals sharepoint site?
This benefit is provided under some plans, but member's are required to meet specific qualifications to receive them.
What are the SSBCI portion of Spendables benefits?
We currently have three transportation vendors that have their own system for routing their concerns. These are the vendors who we do not route through the traditional vendor log. Can you name two out of three of these vendors?
What is MTM, Alivi or Access2Care?
We work with this department to ensure that member's are able to successfully fill all medications and pay the appropriate cost for their medications.
What is Pharmacy?
These two case updates are required if we call the member on a 3rd party case and they take ownership of the grievance.
What is updating the case received date to the date of the call, and changing the complainant type to member?
When the member is indicating fraud or a credit involving their spendables benefit, we would route it to our Member Escalation Team via this system.
What is a CMR MET ticket?
This benefit is available to all members, and does not show in sensentia.
What is Healthy Rewards?
What system would we research to locate a member's plan and benefits information
What is Sensentia
This department is vital in ensuring member's are able to access benefits and providers that they are in need of receiving/seeing for the betterment of their health, regardless of if the benefit or provider is covered.
What is Utilization Management (UM/authorizations)?
This is the amount of time that an AOR form is valid.
What is a one year from the date the member signed the document?
When a member is indicating issues with their spendables account that we can not resolve via our own research, we would use this route option.
What is via email to WellCareSupport@Solutran.com
How would we know if we should route an issue to product or to the vendor?
(For example, if it's about the benefit specifically (not enough coverage), we would route to product. If it's about the vendor portion of the benefit (dental network), we would route to the vendor.)