Claims
Topic used when sending claims back for patient responsibility discrepancy
What is: MC Benefit
Turnaround time for commercial review
What is: 5-7 business days?
First thing to confirm after pulling up a chart
What is: Eligibility?
Agent helps caller with multiple claims on one call
What is: Claims Multiple Patients?
The 3 step communication standards
What is: Warm Welcome, Narrate Care, and Fond Farewell.
DOFR meaning
What is: Division of Financial Responsibility?
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 billed with POS 21 but the authorization was approved for outpatient.
What is: POS/DOS Discrepancy?
What is: CRMs to Utilization Management (UM)
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
Sutter Medical Groups
What is:
*SMF (Sutter Medical Foundation)
• SMG: Sac/Placer, Yolo, Solano,
• Sutter Independent Physicians (SIP)
*SGMF (Sutter Gould Medical Foundation)
*SEBMF (Sutter Eastbay Medical Foundation)
•Central Division
•Diablo Division
*SPMF (Sutter Pacific Medical Foundation)
•Sutter West Bay
•Sutter Medical Group of the Redwoods
*PAMF (Palo Alto Medical Foundation)
•Palo Alto
•Camino
•Santa Cruz
•PAMF-MPD
*Mills Peninsula Medical Group
*Sansum
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