Call Flow & Documentation
A member says they want approval for an additional exam benefit because they didn’t like how the doctor performed the exam. They are requesting a supervisor to override and approve it.
What would you do?
→ De-escalate first (probe, offer to contact provider to redo exam or discuss options)
→ If unresolved, explain limitations
→ CAG (supervisor cannot override or grant additional exam benefit)
A caller provides a member’s name and DOB and asks for claims information.
What would you do?
→ Verify the caller fully
→ Confirm they are authorized (on file, sticky note, super user/approved rep, etc.)
→ Do not release any information unless they are verified and authorized
A non OPERS member requests a new ID card.
What would you do?
→ Process through HSP
→ Do NOT create a B-LOG unless:
• HSP is glitching OR
• the member is OPERS (special case)
A member calls stating they received a bill, but you do not see a claim on file in HSP.
What would you do?
→ Ask how the claim was submitted
→ Advise member/provider to submit the claim if not received
→ Provide correct submission guidance (portal vs paper)
A provider calls asking for an update on a b-log request for a fax of benefits but you see that no B-LOG exists.
What would you do?
Apologize and advise the provider that we do not fax benefits. Advise that the benefits are avail in the prov portal.
Offer to verbally go over the benefits with the provider. (Provide elig token if applicable)
Ensure the provider is in the correct portal to view member benefits.
Offer provider line assistance if troubleshooting is unsuccessful
A member says they requested a form and have not received it. They are frustrated and requested a supervisor.
What would you do?
→ De-escalate
→ Apologize, resend, and offer to expedite via leadership email/ SME
→ Supervisor not required unless still requested after resolution attempt
A member says you can speak to the person with them (spouse/other party), and that person starts asking questions.
What would you do?
→ Thank the member for permission
→ Fully verify the other party
→ Confirm authorization to release information
→ Advise that calls are recorded before proceeding
The date you want is not available in Workforce Management because two agents have already selected it.
What would you do?
→ Submit an exception request through the proper process (leadership email w/ documentation)
A member calls about a claim, and you see it processed out-of-network. The member insists they went to an in-network provider and states they submitted the claim themselves.
What would you do?
→ Verify provider network status
→ Confirm if the individual provider is contracted (not just the location)
→ Explain that member-submitted claims process as out-of-network
→ Clarify how this impacts their benefits and offer to reprocess if the member fights/ requests it
A member calls to report that they still have not received a form that they requested over 5 days ago.
What would you do?
Confirm their email address.
Probe to see if they've checked spam/junk
Resubmit the request and ask leadership to expedite, due to the workflow being overdue.
Apologize and advise member that you have requested to expedite and will follow up.
A member says, “The last rep I spoke to was rude. I want to file a complaint and open a CAG on them.”
What would you do?
→ Apologize & route as a Supervisor call
(Agent complaint, even though they used the word “CAG”)
A member calls asking you to confirm if a specific service is covered, but they refuse to verify because they say, “I don’t need to give all that, just tell me yes or no.”
What would you do?
→ Do not provide coverage details
→ Advise that verification is required before discussing any benefits or PHI
A provider calls requesting a check tracer for a claim.
What would you do?
→ Verify claim status and confirm payment in HSP
→ Advise that check tracers are not completed for providers
→ Direct them to the provider portal or provider support if needed
A member’s claim has been denied multiple times for lack of proof of payment. They state they already submitted it and are upset.
What would you do?
→ Apologize and explain required documentation
→ Offer your email to have them send proof of payment
→ Submit to supervisor/leadership and request to expedite
A dep member asks for a follow-up call on the ph's claim status. They are stating that this has been requested by the ph.
What would you do?
Verify that the dep has verbal or written permission on file from the ph to receive a follow-up. (You must either verbally speak with the PH to confirm, or there must be a sticky note in HSP for release of information. HSP notes will still have to be verified for each call)
Be sure to document interaction in HSP.
A member says, “My employer told me to call you, and you’re telling me to call them. I just want this fixed.”
You see the issue is related to eligibility not being updated.
What would you do?
→ De-escalate
→ Submit to eligibility/update team as needed
→ Set expectations (they don’t speak directly to members)
A member provides information that does not match what is on file (DOB, address, etc.) and insists they are the member.
What would you do?
→ Do not proceed
→ Advise that the information does not match what is on file
→ Refer them appropriately (ex: back to employer/group if needed)
You need to locate an in-network provider for ZIP code 21001.
What would you do?
→ Demonstrate step-by-step provider search (HSP, & API)
A member went to LensCrafters and was told their benefit should be covered in full, but they are being charged. The provider used the Luxottica portal and opted to use their own lab. The member is upset.
What would you do?
→ Explain that coverage may differ when the provider uses their own lab
→ Clarify how that impacts benefits and why full coverage may not apply
→ Set proper expectations
A B- LOG is submitted but missing key details.
What would you do?
Resubmit with the correct details and request to expedite through the leadership/ SME
A member is upset about a denied claim and says, “I want a supervisor because this doesn’t make sense.”
You review it and see that the provider is DDOL for MATS
What would you do?
→ De-escalate and review contracts
→ Escalate only if still requested after proper handling
A member asks you to send their information to a different address than what is on file.
What would you do?
→ Do not send information to an unverified address
→ Advise member to follow proper process to update/verify address before sending anything
A member states they visited an in-network provider, but the office could not find them and said they may not be covered.
What would you do?
→ Verify eligibility and benefits
→ Confirm provider network status
→ Confirm that the facility may be in-network, and the specific provider or service is contracted
→ Explain findings and next steps
A member calls stating they received a bill. You review HSP and see the claim was rejected.
What would you do?
→ Verify all claim details (NPI, address, etc.)
→ If information matches, contact the provider to confirm submission details
→ Identify discrepancies and advise corrected claim if needed
→ If applicable, advise provider to update contract information
A provider requests an EOP because they cannot access their instamed portal.
What would you do?
Submit a request for assistance so the EOP can be sent to the provider via b-log.
*This special process is handled by Samantha B