WorkFlow
When holding a simple adjustment claim for processing & not able to do it in real-time; when should the processing be completed?
A: What is on your next project time to close out the issue within 48 hours.
Exception/Note: If you are able to- the best course is to let it sit for 1 night, so it hits the report in a positive way when you close it out the next day. If it it created & completed the same day; it will not be on the report.
The most critical day of the week you ensure to close as many Service Requests, as possible, in your bucket.
A: What is Friday.
Be mindful that you are not leaving Service Requests open on Friday, as they will go over TAT with the weekend.
What is the total closed number for team Veeser IR-48 on the most recent email?
Define Business Unit.
A: What is ORS routed out of your team, closed by Business Partner.
What guidelines do you follow for member submitting first pass claims?
A: What is line 11 on the WF.
If Members First Attempt To Submit Claim No Commitment Needed To Be Open. Can provide RMO fax.
The September IR48 Goal for Elite?
A: What is 67%.
Note: 2020 Goals will differ from month to month.
Define Unit.
A: What is ORS closed within your team.
When waiting on member provider to send in additional information after an outreach to them, does the service request stay open?
A: What is once the provider is reached, the service request will be closed until we receive required information.
Notating why you would have a B Commitment Code.
A: What is Monitoring the Account.
Required Documentation:
-Agent must document that the commitment is an urgent/escalated situation
-Why the account is being monitored
- What the expected outcome is
What is our current percentage for Kielar Elite? (based off most recent IR48 email)
A: What is See email""
After a provider outreach & receiving additional information, do we re-open the same service request or open a new one?
A: What is open a new one when you have the FLN & route to designated area.
Define IR-48.
A: What is Issue Resolution within 48 hours.
Note: Weekends count against the 48 hours.
Number of attempts to reach an INN provider for a Balance Billing Issue.
A: What is 1 attempt.
Note: Outreach to the provider on the initial call. Even if no answer, route a BB letter request as needed (1 ICN per ORS). Member will receive a copy of the letter.
ORS Documentation:
Member's contact information
Name of billing provider
Amount being balance billed
ICN
DOS
Details of conversation with provider (if able to reach)
Indicate that request is for initial balance bill letter, second letter, etc.
How many ORS do we show have been closed in 2 days for Elite, based on the most recent email?
A: What is:: see email.
When a member calls back in about the same issue, 4 days after the first call & you have to route an issue; do you re-open the initial ORS or create a new one?
A: What is Re-Open the initial ORS.
Note: If the issue is EXACTLY the same (Same ICN, DOS, Provider, FLN, Etc) you will Re-Open it. If you have new/different information, you will create a New ORS.
What information is needed for a cob update to be completed in a timely manner?
A: What is follow the template & fill out all information, so we are not needing to try to contact the member back to gather additional information.
A: What is the Template & routing the ORS.
This is when the IR-48 Report is generated.
A: What is Overnight.
ORS that are created & closed the same day, do NOT hit the report. Be mindful to not close your ORS in the same day of creation. Close it the following day, so it can positively impact the report. Exception: Fridays.
What is the total percentage that team Veeser is at based on the most recent email?
When is it acceptable to reopen an ORS that is over the IR48?
A: What is when it is closed in error.
A: What is unresolved, repeat issue.
Note: If the below information is NOT the same, you will need to open a NEW SR ORS to Route for completion. You will then CLOSE your current one. We don't want to be re-opening CLOSED ones, unless the following is true: