Process Task
Patient found in system but the agent does NOT have access to the plan or cannot locate correct department. How do we process task?
Select: Invalid Task; Terminated or Invalid Plan
If the provider is Out of Network (OON) what do you do next?
PB to check the network status of the practice
No other insurance, plan is primary. Line 17
Agent states "It's the patient's responsibility to keep track of their accumulations."
PB "Has the deductible/OOP been met in full?"
If met: Input the limit/max
If not met: Headset accumulations. Add TN.
Bonus point: Name the line number and TN to include.
For PA the agent says "I can not answer if it is required", what do we do?
We will escalate at the end of the call.
Agent refuses to speak with Digital Assistant. How do we process task?
Select: Payer issues; Payer won't speak to Eva.
On a call they say are you INN with your local? What do you do next?
PB. Can you check that please?
Agent states there is unknown other insurance on file and is unable to answer current plan priority. What are the next steps?
PB once "Can I have the benefits as if you are the primary provider?", if yes:
Other Insurance: Yes
Other Insurance Name: HEADSET
Plan Priority: Primary
If agent is unable to answer if the SOV copay applies regardless, but the copays for admin and OV are the SAME, who do we escalate to?
No escalation required, mark copay always applies.
Line 51
If PA on file is expired for a different provider, how would we enter it?
Not on file.
Agent states that the plan is handled by a different department and they can not transfer. How do we process the task?
Select: Change Phone Number
If the provider is OON and the practice is OON, what do you do next?
Prompt What is the procedure to obtain in-network consideration?
True or False: A commercial plan can be secondary to Medicare A & B?
True
If the deductible is included in the OOP, but the deductible met amount is larger than the OOP met amount. What do we do?
"Can you explain why the deductible accumulation is greater than the out of pocket accumulation?" (If the deductible met is greater than the out of pocket met)
Agent agrees PBV PA is on file, start dates match but end date is further out. How do we proceed?
Input agent response, no escalation needed. Continue call.
How do we process a task if we forgot a PB or prompt?
Select: Operator Error; Unanswered Questions/Incorrect Answers
For BCBS, the provider status is unknown and the provider is not listed on the website. What do you do?
Select Unknown and collect both INN and OON. If the plan has no OON benefits, add TN and collect INN.
Agent states payer administers the Medicaid and provides 80/20 coinsurance for J-code/admin/OV, what should you do?
Change "payer administers" to "state administers" to reflect cost share provided. Line 9
Agent states J-Code has a $60 copay, no coinsurance, which matches KG/PBV, what pushback do you use?
None, leave field locked.
Agent states OptumSGP is the delegated medical group for the plan, what questions do we ask next?
Continue to ask all referral/PA/PD/ST questions on platform, OptumSGP is not a medical group.
How many attempts must you make for unreachable before we can fail?
4
What is the correct TN you use when we collect INN benefits for the practice?
Collected in network benefits based on practice network status.
If the agent can not answer "How this plan coordinates" what do you do?
You PB once and then escalate at the end of the call to a Supervisor if they still can not answer
If the agent says the J-code is not covered, and it goes through a PBM even after PB, what are the next steps we take?
There is no PBV available.
If still through PBM:
Can you give me the name and number for the pharmacy benefit manager?
If NO PBV or is the second attempt: J code Valid & Billable : No.
Why not covered? No RX Benefits - drug covered under PBM
Continue the call & collect Admin & SOV/HOV benefits. Obtain reference number, GE and add task note.
Agent states PA is valid from 1/1/2024 through 1/1/2025. PBV states PA is valid from 1/1/2024-11/30/2024. What are the next steps and why?
Escalate to confirm PA approval dates since end date is more than 7 days shorter than PBV PA end date.