Claims
Topic used when sending claims back for patient responsibility discrepancy
What is: MC Benefit
What is the retro request policy for Medicare Plans
What is: UM will not review
First thing to confirm after pulling up a chart
What is: Eligibility?
Agent helps caller with the claims address, fax information or phone numbers
What is: Other
The 3 step communication standards
What is: Warm Welcome, Narrate Care, and Fond Farewell.
For Sansum claims before 11/2025, how would we proceed?
What is: Advise you would have to transfer to Sansum backline, and it may be a voicemail option, then warm transfer
Step for patient to do if they want to dispute a denied authorization request
What is: File a grievance with the plan
Process health plan use to report eligibility
What is: Health Plan Files
Agent helps caller with multiple auth requests/status etc. on one call
What is: Auth Multiple Patients?
Commitment Statements
What is: A statement to demonstrate an eagerness to assist the patient?
Examples: definitely, certainly, absolutely, my pleasure I'd be be happy to I’d be glad to… I’d be pleased to… I’d be delighted to… (more enthusiastic) I’m happy to… I’m glad to… I’m more than happy to… (extra accommodating) I’d be more than willing to… I can absolutely… / I’d be happy to help… I’d be glad to assist with… I’d be happy to take care of… I’d be happy to look into… I’d be happy to connect you with… I’m eager to… (strong eagerness) I’m excited to… (upbeat) I’d welcome the chance to… (more formal) It would be my pleasure to… (very formal
Claim was rebilled as a corrected claim but is being denied as a duplicate, what do you check?
What is: Box 22
When a caller has received an approval, but the CPT codes are different from the ones sent on the fax, what smart phrase would you use?
What is: UMUPDATECPT
How long is a newborn covered under the mom's ID
What is: 30 days?
Claims sent for research by CRM or Email. Faxed EOB(s)
What is: Claims Research?
Acknowledgement Statement
What is: Paraphrasing/repeating back to the caller what was asked *Phrases such as, "I can help you with this/that" or "Sure, let me pull up your chart" are unacceptable to use as a Commitment & Acknowledgement Statement as they do not contain an eagerness keyword and are not specific to a request
CRM Sub-topic to opt out of credit card payments with InstaMed.
What is: Opt Out CPC InstaMed
The number to direct callers calling regarding Pending Concurrent Review, Inpatient/SNF/Transfers/Rehab
What is: Case Manager: Inpatient/Transfers/SNF/Rehab
916-649-4155
Steps to terminate a coverage in EPIC
What is:
Calls that require contacting UM. Fax and Auth Letters
What is: Authorization Research?
Engages in non-work-related activities (e.g., personal email, messaging, or internet use) during calls or After Call Work (ACW) Screen activity reflects use of applications or websites unrelated to the call Demonstrates inactivity exceeding: 30 seconds or more during ACW 1 minute or more while the caller is on hold Examples include (but are not limited to): Unrelated browsing or page scrolling Personal chats or messaging Excessive mouse movement without work-related purpose
What is: Misuse of Time
An escalated issue is defined as an issue where patient/provider has called multiple times on the issues without resolution. Other request that can be sent here are for Letter of agreement(LOA), Hospice date verification, CAP Report.
What is: The MCA Box
Referrals that requires additional information from either referral navigation or referring provider or other work queues.
What is: Care Ctr/Clinic Action Needed referrals
How to find medicare attribute
What is: Navigate to coverages
Click on Open
Navigate to attributes
Care Center Action Needed Referral not assigned to UM Missing information
What is: Incomplete Referral?
The behaviors that fall under appropriate customer service standards
What is: maintaining a tone that is polite, professional, empathetic, and confident throughout all interactions
Uses pleasantries and courteous language consistently. Speaks clearly with confidence. *Confidence should be void of sarcasm or any negative connotation towards our organization, processes, or professionals Uses tact and maintains professionalism