Let's get ready to MAPD

Healthy Today Card

100

Five Healthy today flex card Participating Retailers 

Walgreens

Kroger

Walmart 

Rite Aid

Tom Thumb 

200

The vendor that will be handling the healthy today card

Who is Convey 1-866-851-1579.

300

Can a member increase or add a benefit offered through the health today card through organization determination process?

What is no, however you can offer to do a search of plans in that members area that may include that particular benefit/allowance.

400

A cigna customer happily using their cigna healthcare benefits to pay their July light bill. 

What is the member can use their Cigna Healthy Today benefits flex card to pay their utility company via online, customer service or IVR system. 

• Article Number

  000058972

  
  

500

Can customers use their flex card to order OTC products if they do not have the OTC benefit? Provide KX Article

What is yes if they have received CMAI incentives and funds have been loaded on the card

• Article Number

  000058972

  
  

What do I do?

100

Member switched to another MCO during OEP and wishes to come back to Cigna. Hint: It is still OEP Provide KX article

 What is transfer to sales 1-800-870-2169 to complete a new application.

• Article Number

  000033547

  Important! Customers can only make one change during this period. Important! Customers can only make one change during this period.

200

The customer is upset and requesting to be transferred to Medicare? Please provide KX article

Article Number000021650

• When customers are referred or transferred to Medicare, we are at risk for receiving CTMs. CTMs lower our star ratings.
• It is essential to always try and resolve the customer or provider issue without contacting Medicare. CSAs should always refer customers to Medicare.gov, to a SHIP counselor or to the Social Security Administration website or by phone to 1-800-772-1213 before referring them to Medicare.
• Note: Do NOT automatically transfer or refer customers or providers to Medicare. Please refer to the procedures below for further instructions
• Note: Do NOT transfer or refer customers or providers to Medicare unless absolutely necessary. If a caller expresses that they would like to be transferred to Medicare, complete the following:
• Verify if one of the following common scenarios applies and complete the applicable resolution procedure:
• 
  
  2. scalate the call to supervisor or team lead to facilitate a conference call with Medicare.
•  
  Note: The supervisor or team lead will first try to resolve the issue, and if they cannot they will conference call the member with Medicare. Supervisor or team lead will inform the Medicare agent of the following:
  • Hello. My name is <name> with <Plan Name> and our customer is requesting to speak with Medicare.
  • This is not a complaint, I am just making sure the customer is connected with your office.
  • Go ahead (Mr. or Mrs. Last Name). Medicare is on the line.

300

Member is calling in to change from a preferred HMO plan to a true choice PPO. How do you proceed with the call? Provide KX article

What is determine if customer has a SEP then proceed with applicable scenario. 

• Article Number

  000033586

  
  

400

A customer is requesting to be transferred to Medicare to disenroll. Why is it important that you complete all compliance requirements for this call and what are they?

What is follow Article Number 000028398.

Contact support chat to initiate warm transfer 

(It will automatically result in CTM if CSA fails to offer all four disenrollment options or miss any other part of compliance components.)

Inform customers of all disenrollment options.

• Customer chooses the option to compose a letter requesting disenrollment.
• Customer chooses the option to be mailed a Disenrollment Form.
• Customer chooses the option to enroll in a Prescription Drug Plan (PDP) or a new Managed Care Organization (MCO) other than Cigna.
• Customer chooses the option to call 1-800 Medicare (Conference call will be facilitated by Chat Team Leads/Supervisors or the enrollment queue agents only)

500

A customer called to request proof of enrollment status in writing. How do you proceed with the call?

Provide KX article

What is follow Article Number 000034609

If a customer requests proof of enrollment status in writing

1. Educate on the effective dates. Note: Customer can request proof of enrollment status for previous years.
2. Document the effective dates in OneView/QNXT.
3. Educate the caller you will be requesting a letter.
4. Confirm the customer’s address. Note: Update the address if incorrect.
5. Create a call task/call tracker.

 One View

• Request Category:  Eligibility 
• Request Name:  Eligibility Verify or Eligibility Status
• Resolution:  In Progress
• Comments:  Paste your documentation 
• Reassign Queue:  GOV-MCAREMASENROLL

RX

100

How does a member get a copy of their total OOP for 2022 that they paid for prescriptions?

What is request a full rx EOB material request in QNXT. Assign to .CSADMIN

200

Member has received a denial for a narcotic prescription at the pharmacy.

What is the member can request to get a 7 day fill or the member can request a CD for the full month ahead. 

300

Where do find how much a specific cost of a drug?

What is you can run a test claim to determine the cost or you can search the tier of the drug and then look at the tier under the health plan id.

400

A prescription has been denied due to a refill too soon.

What is outreach to pharmacy resource to get a waiver 877-376-7104

500

A member calls in to get a replacement glucose meter. How to proceed with call? Provide KX article

What is determine if meter is covered as preferred or non-preferred 

• Article Number

  000057965

  
  

Appeals

100

The processing timeframes for a standard appeal and expedited appeal

Standard:

• 30 calendar days for Medical and Dental.
• 7 Calendar days for Part B and Part D medications
• Article Number

  000047734

200

What is the right to ask for a State Fair Hearing when Cigna upholds its original adverse determination in whole or in part for a Medicaid benefit/service. 

Article Number

000033444

Medicare customer appeal right(s)

300

Name the person(s) that can file an appeal on a customer's behalf:

Article Number

000053520

An appeal can be filed by:

• Customer,
• Customer's legal representative
• Customer's doctor, or the staff or medical assistant of the doctor that is acting on behalf of or under the direction of the provider. 

400

True or False: Once a provider requests a peer to peer review, it is certain that they will receive a callback to complete the P2P review?

False

Article000053520

Peer to Peer requests are not guaranteed and must meet guidelines for a possible call back from Medical Director.

500

The second level Federal Service that reviews denied appeals

Article Number

000041986

What is Maximus

Dental

100

Are implants covered under all dental plans?

What is no. Implants are only covered under the dental allowance. Implants are not covered under the DHMO (see customer's plan)

• Article Number 000037486

200

How to determine a DHMO copay?

What is pull up the member's account in webster and locate the charge schedule number. Then go to the KX ARTICLE 000064170 to locate the charge schedule. NOTE: This only applies if you are dental trained if not, please transfer to the dental queue.

300

A member calls in to locate a provider.

If dental trained, you would utilize webster for DHMO plans kx 000011399. If you are not trained, please transfer to the dental queue. 

400

A customer has maxed out their dental allowance for the year, but wants additional dental coverage. How to proceed with call?

What is educate the caller they can purchase additional coverage with supplemental plans.

Article Number-000015211

500

What happens if a member using their max dental allowance for the year?

What is the member will be responsible for anything of the dental allowance amount 100%