Valid or Not
UCID: 000322342093/ PHI: Y / Issue Identified: Per Review of Call recording Dated: XX/XX/202X- • GRV 1: Member called to make a payment for his accoutn and for his wife’s account. Member was upset that he had to spend half an hour on the phone just to make a payment.
Valid
Member was unhappy with service they received at the Pharmacy
Who: PNO
How: Disposition PNO Referral in the grievance case
Needs to be accessed for every grievance, where you can find call notes
Notes Hist
Member stated in correspondence that they were unhappy with their premium increase
Closed-Written
What does "OHI" stand for?
Other Health Insurance
UCID: 0005543423/ PHI: Y / Issue Identified: Per Review of Call recording Dated: XX/XX/202X- • GRV 1:Member asked when their invoice was going to be mailed to them
Not valid
The member was not happy because they received a bill from the plan due to an adjustment to a previous medication claim
Who: PNO
How: Email PNO at "PharmacyOps@healthspring.com"
Access this tab to determine when the member's recurring payment on file was set up
Pay Methods
Member called and expressed dissatisfaction with the length of time they spent waiting to speak to a representative. A grievance was offered and the member agreed saying that he would be expecting a call from us.
Closed-Verbal
Where can you find the Coordination of Benefits Survey letter that is sent out to the customer?
Mail Hist
UCID: 0009938223/ PHI: N / Issue Identified: Per Review of Call recording Dated: XX/XX/202X- • GRV 1:Member said that previous advocate was rude and constantly interrupted them on the phone
Not valid
The member was unhappy that they were not receiving their invoices in a timely manner and said that they were going to talk to their lawyer
Who: Cigna
How: Email "CignaPDPGrievance@Cigna.com"
Needs to be accessed whenever you work a case, helps you determine if your case needs to be cancelled as a Duplicate
Grievances/CTM Complaints
The member said that they hated dealing with the IVR system. When a grievance was offered the customer said "no no, I don't need that. I just want my payment to go through."
Inquiry-Not a Grievance
Without a Prior Authorization, what is the maximum number of days that a Opioid medication can be filled?
30 days
UCID: 0099983223/ PHI: Y / Issue Identified: Per Review of Call recording Dated: XX/XX/202X- • GRV 1: The member tried to get their medication at Safeway Pharmacy but they had to wait a very long time to get it.
Valid
7-day case where a then unauthorized third party is grieving about the service they received at a pharmacy. Authorization was received after filing. No referral was made at the time of filing.
Who: PNO
How: Disposition PNO referral in case and then forward email to PNO_QOC_Pilot_Escalation@conveyhs.com
Access this tab to determine when the member's enrollment was approved by the Centers for Medicare and Medicaid Services
CMS Response
The member was angry and confused when they received an Exh. 19 letter. MSR apologized and explained the letter and what FTP was. After providing them with their past due amount, the MSR offered to process a one-time payment and set up the member for recurring payments to which the member agreed to both. At the end of the call the member was grateful and did not have any more problems.
Resolved by MS Rep on call (Non-Simple Grievance)
Cigna Healthcare does not request payment for underpayment balances of $_____ or less
$5
UCID: 0009993322/ PHI: N / Issue Identified: Per Review of Call recording Dated: XX/XX/202X- • GRV 1:The member was unhappy that their CD request was denied
Invalid
The member felt mislead about their benefits by the person who they spoke to during their phone enrollment
Who: Internal Department (answer will be the email)
How: Email "AgentBroker_Grievances@conveyhs.com"
What three tabs need to be accessed to determine if a third party has authorization
The customer was really unhappy because they said that their doctor's office has once again messed up their prescription order.
Inquiry-Not a Grievance
What is the cutoff date for when you can use the "New Plan Benefits" categories?
May 31st