Complaint Process
Can you check the escalation box on a normal case and PA case?
Yes
Altaria
In the example below does the name qualify to be considered first and last name for Smithrx Verification?
Name is Jane Doe-Smith
Caller provides Jane Doe
No , if account has "Jane Doe-Smith" , the call will not pass verification if the member verifies as Jane Doe or Jane Smith
Article used to collect information about a provider and send them a Prior Authorization when its needed?
Prior Authorization (PA) Workflow.
When is the recorded line statement required?
Recorded Line Statement
The first time the call comes in and is answered, we don't need to let the caller know that the call may be recorded or monitored because our IVR states this prior to us answering the call. However, any time you speak with someone new, it is required to inform them that the call may be monitored for Quality Assurance Purposes. Examples of when you must use the recorded line statement are below:
Examples:
“This call may be monitored or recorded for quality assurance purposes.”
“Hello, this is (name) with SmithRx on a recorded line."
Provide one example of a complaint you would create a complaint case for?
Bonus 100 points per person that has an example. TL will go around the room.
Celebrex
Medication
If a caller/account member is calling for someone other then themselves what article should we use at this point? (age of member doesnt matter)
MSS Approved Advocate (AA)
What do you do if the member is not okay with waiting 15 days for an answer on their Prior Authorization?
What shelf do you use?
Ask discovery questions to see if they qualify for the expedited time frame.
Prior Authorization PA Workflow.
Name an article the recorded line statement is in?
Call Verification
What is required in the notes of a complaint child case?
Reason for complaint.
How it was resolved or what will be needed to resolve.
Sentret
Pokemon
Sentret is a Normal-type Pokémon known as the Lookout Pokémon, which stands on its tail to keep watch while others sleep.
In the example below does the name qualify to be considered first and last name for Smithrx Verification?
Name in C3 is Jane Doe Smith
Caller provides Jane Smith
Yes , If "Jane Doe Smith" calls, the member needs to provide Jane Smith to pass verification. The member could also provide Jane Doe Smith.
Article to use when a medication is not covered in C3?
Not covered (NC) Workflow
If a SmithRX agent transfers a member to you , do you need to do call recording?
No
Although, You will not be negatively impacted if you do it.
Fill in the blanks.
Case reason will ________be ___________
and is ________ for _________cases.
Always
Complaint
Required
Complaint
Luxray
Pokemon
In the example below does the name qualify to be considered first and last name for Smithrx Verification?
Name in C3 is Jonathan Doe
Caller provides Jon Doe
No, If the member's account in Salesforce/Portal says "Johnathan Doe" and the member provides "John Doe" or “Johnny Doe,” that WOULD NOT pass verification.
Article used for Reject 79?
Laker Reject Code Workflows
or
Override Request Workflows
Why do we provide verification to anyone that joins on the line?
To ensure everyone knows they are being recorded since they did not hear the IVR stating they would be recorded.
Why is the complaint process important?
URAC
Duloxetine
How many pieces of verification for a member that is transferred or comes on the line while you are talking to another caller that does not work at SmithRX?
3 pieces
Article used for member coverage?
Drug Coverage
How many times would you need to provide call recording in the following scenario.
Caller calls in to help their mother with their medications. The member comes on to the line and is verified with 3 pieces of info and adds their daughter for 10 years. You then call the pharmacy to ask them to update something and they place you on hold 3 times during the holds you talk to 3 different people. They fix the issue then you end the call with the pharmacy and the new AA.