Call Flow
This is the act of repeating key details back to the member to confirm understanding.
Recapping
This metric tracks adherence to scheduled work times
SCAD
This should be done before discussing account-specific details with a member.
Verify the member
This resource should be used when you are unsure of a process or policy
E.Policies
Remains Not Covered
Weight Loss Medications
This shows understanding and concern for the member’s situation.
Empathy
The Metric for Scad
94%
True or false? You can proactively provide medication names to members.
What is false?
This should be pulled on every call for plan specifics
PSPP
Sort doctors and facilities into tiers based on their performance and ability to save money.
Multi tier plan
This step explains available options to the member before closing the call
Offering ISM suite of services
Evaluates the quality of interactions based on predefined criteria, such as colleague professionalism, accuracy, and adherence to scripts or guidelines
ACE
Can be provided to pharmacy staff to locate the member.
What is the alternate ID?
If unable to they can update credit cards on file.
Who is the Senior team?
Must be within 25 miles of the members home, a tier 1 (Maximum Savings), provider is accepting new patients, and correct provider role.
PCP Choice Criteria
Should be offered on each call to allow the opportunity to reflect on members experience
What is the survey?
73.3% to meet
What is NPS?
True or False? You can opt a member's spouse out of Maintenance choice with out consent.
What is false?
You have done your due diligence and still need assistance.
What is contact the EMT line?
a benefit that provides each enrolled member up to 5 services from a pre-defined list of in network services covered at no-cost (100% paid) prior to the application of the deductible and/or coinsurance.
Flexible Five
Medical, dental or pharmacy?
What are the suites of service?
You will save on this if you conference the member into the call.
What is hold time?
If you fail to validate the caller you can expect what?
What is a critical error?
This should be accessed on each and every pharmacy call.
What is the CIF?
Non-emergency charges incurred outside of the United States, Home births, Cancelled or missed appointment charges or charges to complete claim forms, Services for or related to the following types of treatment: aromatherapy; sensory or auditory integration therapy; primal therapy; rolfing; psychodrama; megavitamin therapy; bioenergetics therapy; vision perception training (vision therapy); or carbon dioxide therapy
Plan Exclusions