Pega Work Instructions
Template that must be used when creating provider follow up
Member Information:
- Patient name (if minor, include parent name on file with facility)
- Patient DOB (if minor, include parent DOB on file with facility)
- Patient's Phone # provider has on file: (verify the one in the account is correct. If not, update demographics as well.)
- Patient Address provider has on file: (if member has a temporary address, verify with a member which address was provided to the facility.)
- Has a member called UCare about this more than once?
- Has the member received more than one bill?
- Has member been sent to collections? (Tag case by using pound- #Collections)
- Is the caller different from member who received the bill (Ie. a parent calling for a child's visit?)
Note: If the member is a child/dependent under age 18, please include parent/guardian's Name and DOB.
Provider information: If member doesn't have a physical invoice/bill in their hand, advise you will set up a provider follow-up when they receive another bill.
-Patient Account (aka guarantor #, not UCare ID)
- Facility name (if provider name is listed above)
- Claim # (if available)
- Is the billing provider name different from the clinic location where the member went?
- Does the billing provider have any other phone number on the bill member received?
- Have the member reached out to the provider about the bill? What did provider advise?
- If a claim is already on file, did you offer appeals and grievance rights to a member? If you did offer, why does the member still want UCare to follow up with the provider?
Share an article with teammates
PEGA go to article and click on 3 dots
Will need this information from member when calling Navitus
Member calling to follow up on ID card that has not been received, where would you verify it was sent.
Add task, ID card, order history
Member calls with issues with their mail order for drugs
Quality concerns-Navitus and Costco intake forms
(Trans to Costco Mail Order)
How would a member who has not submitted a voucher for a screening collect their reward.
If member calls stating they have been seen and are requesting a reward be added, please locate the medical claim or dental claim first, and then send the following information to Health Promotion via an S-case:
Which of these Compliance Forms CANNOT update demographics:
Statement of Representative
Member Release of Information
POA
Member Release of Information
PEGA What's the difference between these forms
Member calls requesting to file an appeal due to denied claim (even when it is a provider responsibility) Do you still offer appeal?
YES or NO
YES
A company that is contracted with us for two different types of services - subrogation and call campaigns.
Optum
PEGA Optum
What are the 4 C's for documentation
• Clear
• Concise
• Correct
• Complete