Review 1

Inquiry Basic Terms

100

What is the percentage of a covered service that you are responsible for paying or the percentage paid by your plan called?

Coinsurance

200

What is the fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins called?

Deductible

300

What is the fixed dollar amount you are required to pay for covered services at the time you receive care called?

Copay

400

What is the maximum amount the member pays out of his or her pocket as indicated by the insurance plan called? (Once this is met, the insurance plan pays 100% of the allowed amount for covered services.)

Out - of - Pocket Maximum

500

What is the statement sent to the member after a claim has been processed that summarizes the claim, including the level of benefits applied to the services, the deductible applied, the provider of services, and any denial of services with the reason for the denial called?

Explanation of Benefits (EOB)

Programs/Tools

100

What is the web-based application that houses procedural information, screen prints, system prompts, and other reference information that you need to perform your job called?

BlueSource

200

What is the online system used to document inquires?

Dashboard

300

What is the toolbar within Dashboard used to perform telephone related tasks?

Softphone

400

What is the tool that allows you to quickly access your most commonly used programs, folders, files, and web sites?

Automation Team App

500

What is the application that assists the operator in performing tasks to quickly access, navigate and enter information into emulators?

CMMouse

Required Call Task

100

What are you required to verify after asking permission to ask the customer questions?

Subscriber Number

Caller Name and/or Member Name, if required

Date of Birth (Caller's and/or Member's as required)

Phone Number 

200

What is the standard notation form when documenting your call?

ttec Pad-DT U#

Q(uestion): 

A(nswer):       

R(esources/Resolutions): 

300

What are you required to do/say before quoting benefits to a customer?

Prior to benefit: The quote I will give you today represents your highest level of benefits and lowest out of pocket cost when utilizing one of your policy’s preferred providers.

After Benefit

Do you need me to verify the status of the provider you will be using?

If provider is found to be non-preferred, you will then need to quote that benefit level or ask if they would like assistance locating a preferred provider.

You will not be required to quote alternate levels of benefits unless requested.

• Examples: Multiple-level tiering or Out of Network benefits
• Exception: Benefit quoting application indicates only one level of benefits

Important Notes:

• This process excludes RMO and HMO; you will continue to follow your normal workflow.
• When quoting benefits, for each benefit given; it is necessary to advise the caller "of the allowable amount."
  • However, If the provider is Out of Network, we must advise the caller "of the allowable amount" and that the "patient may be responsible for any amount over the allowed amount".
• If the member has an HMO policy and you are unsure of the provider's network status (In or Out of Network for the HMO), then advise the caller that only In Network benefits are available. Services rendered by an Out of Network provider may not be covered, with the exception of emergency services, or services provided could be eligible with authorization.

400

What must you say at the beginning of every outbound call?

Hi, this is <name> and <title> calling from Blue Cross Blue Shield of <Illinois, Montana, New Mexico, Oklahoma, or Texas>. I want to let you know this call may be recorded."

500

What is recommended call flow? (Ulysses steps)

1. Acknowledge The Customer (Issue/Emotion)

2. Gain Control With An I Can Statement - Be Specific

3. Transition to Probing

4. Probe With Situation, Issue and Validation Questions

5. Provide Solutions With Options

6. Gain Acceptance

7. Recap and Provide Next Steps

8. Ask "Is There Anything Else?"

Programs/Tools 2

100

What is the application that allows you to access information from various systems while only using one system which allows you to resolve many of your inquiries without the need to launch to other applications?

CA Portal

200

What provides CAs and other designated staff with the ability to view information about an individual member and their dependents?

MPUI (Membership Profile User Interface)

300

What is an application designed to improve the quality and accuracy of benefit inquiry responses by providing on-line, real time access to a member's benefit information?

Real Time Benefits (RTB)

400

What is used to view detailed membership information not located in other files, such as HIPAA authorization for group administrators and producers, determine if there is a religious exemption for well woman coverage, and order ID cards?

BlueSTAR

500

_________________ is a Pharmacy Benefit Manager. Several Blue Cross and Blue Shield plans contracts with ________________ to provide pharmacy benefit management and mail order pharmacy services to BCBS members.

PRIME Therapeutics

Final Jeopardy

500

What plans propose to keep medical policy costs for employers lower than other traditional types of medical insurance without compromising quality care for their employees and what is the main feature?

Consumer Directed Health Plans (CDHP) 

Main Feature:

high deductible/PPO plan paired with either a Health Care Account (HCA) or a Health Savings Account (HSA)