Systems
What system would you begin and end a call with?
Maestro
Member calls in to change a PCP. What intent would you use to document the call?
Search and Assign Provider
Name 3 types of Macess Routes
Enrollment Route
COB Route
Member Materials Route
What is the call closing that is required at the end of your call?
"Are you satisfied with the service I provided today?"
What call type would you select to transfer a member?
Warm Conference
What system is used to look up all standard operating procedures?
Knowledge Central (KC)
Member calls in to find a new PCP but their plan is no longer active. What intent would this call be documented under?
Eligibility status
Member calls in and you determine the account is no longer active. After checking the state system you determine the state shows the member should be active. What route would you submit?
Enrollment route-->Eligibility Discrepancy
What are the limits for Hold time and Dead Air time?
HOLD- 2 mins
Dead Air- 10 seconds
Member's wife calls in wanted to change the member's PCP. Wife IS listed as an Authorized Representative. Can PCP be changed?
NO. Authorized Reps CANNOT make any changes without verbal permission from the member.
Site members can access to find a copy on their member handbook.
Members calls in with a Medical Emergency. After call has ended, where would we document the call and provide an acceptable example.
CSP Facets
Should Include:
Member calls in and requests an AR form be mailed to them. What route would you complete for this member?
Member Materials route-->Release of information form
Member calls in and states they do not want to be recorded. What is your response?
Advise member that callback can be scheduled with a supervisor within 24 hours.
Where can members go to view their own claims, change phone numbers/emails, and view and download their virtual cards?
myuhc.com--> member profile (aka Member Portal)
The main phone system used to handle incoming member calls is called?
Virtual Call Center (VCC)
Member calls in to schedule transportation for an upcoming appointment. What intent and category would you use to document this call?
View Member Benefits >> Transportation Benefit
After entering all information needed for a COB, before saving and submitting the route, what is the last selection you must make on the Details page?
COB Request Options --> U- Update COB
DAILY DOUBLE!!!!
Reach out to SME in chat.
Transfer case in Maestro to SME.
Transfer call to DVS SEL line.
Member calls in and reports that they are expecting a baby. Member wants to know if we can help with expenses/needs for her pregnancy? What would you offer to the member?
Healthy First Steps/Baby Blocks Program
System used to confirm questions on eligibility for a member. Not a UHC website.
MITS- OH
ePaces- NY
eCis- PA
DAILY DOUBLE!!
Advise caller the health plan does not make those permanent changes and direct them to State.
If member has already updated this information with the state, the change will be made once we receive the enrollment file from the State.
Eligibility Status Intent-->Provided State Medicaid Information
What steps must you complete to save and submit a route before closing Macess? (4 Steps)
Hit Floppy Disk
Hit F4
Hit Train Icon
Copy SF #
Caller has a Medical Emergency. What information do you need to gather to pass on to your supervisor and authorities?
-Caller's name
-Caller's current location: Address, city, and state
-Caller's specific location at the site
-Details of the emergency situation
-If the caller is alone, are any pets loose where the caller is located, and is the caller able to open the door for Emergency Services?
Member calls in about an EOB that had a different DOS listed, than when she visited the provider's office. Is this an example of possible fraud?
YES. It is possible that the provider purposely adjusted the DOS to manipulate the insurance coverage for the billed services. Issue may need to be escalated.