What's the Rx 411?
Member calls with provider on the line. During the conversation, the provider is advised an Rx needs PA. The provider asks the agent, " Can I do that now?", "Is there anyone I can speak with to start the process?" The CA tells the provider no.
Question: Was this handled correctly?
NO-
Agents can transfer a provider to initiate a prior authorization. Always warm transfer the call.
Self-administered ext. 5644
Provider administered ext. 5636
Who is the Manager of Operations for U500?
Benton Amos
What is Member Experience?
Member experience is a member’s overall feelings after interacting with us. This opinion is based on their overall impression of our services and behaviors. Services are the things we provide. Think of behaviors as how our services act in the eyes of our members. For example, how we communicate, which involves the channels and perceived tone of our communications through each channel.
Quality
RAP
Member called asking why LAB claim was processed Out-of-Network. Her doctor was In-Network. The agent researched to find: The In-Network physician sent the labs to an Out-of-Network LAB.
Question: What is the agent's next step
1. Check CAA- surprise billing guidelines
is this a surprise bill
2. send to research for adjustment
3. Advise member of timeframe adjustment
Where are PA approvals loaded in CVS?
Manage Overrides (left pane link)
Name the U500 Supervisors
Jamesetta Wilkins
Erica Alexander
Diane Murphy
What database can agents use to access individual Agent Utilization, Quality, and FCR?
Performance Dashboard
Agent Utilization
BLUES
Give 3 methods providers can use to request Hi-Tech Imaging PA?
Availity
Via Phone
Fax
Where can you find status of Rx PA?
Novologix
Name U500 Team Leaders (TTEs)
Natasha Smith
Deirdra Norton
Deonne Hamilton
Johnathon Brackett
Shandra Westley
List the 3 categories members fall into with Net Promoter Score (NPS)
Promoters
Passives
Detractors
Hold Time
COUNTRY
The member called stating her Rx denied and the pharmacy said it's not covered.
The CA reviews Rx claims and doesn't see a denied claim.
What happens next?
The CA should call the pharmacy:
verify, find out what took place.
Make sure pharmacy is running correct insurance info etc.
Formulary changes /drugs requiring PA (2025)
Where are copies of letters located?
Agent Workspace- Outreach Tab
or
Pharmacy Solutions Portal
BCBST President and CEO
JD Hickey
Member called customer service 3 times checking status of grievance. She mailed the info 2 times and sent an email. She's very upset.
CA checks, nothing is on file.
What are next steps?
-advise member to send documents to your attn via fax
-upon receipt CA/TTE will forward to grievance dept.
REGGAE
Ozempic Rx denies for (MM) and there is a drug shortage. The member is out of medication. What is the best solution/option for member to get Rx?
CA needs to RT inquiry to Rx411 bucket to get an override for 30 day supply.
What is the turnaround times for expedited and normal PAs? (Prior Authorization Fairness ACT) 1-1-25
Expedited PAs: 72-hours
Normal PAs: 7-days
BCBST Executive VP and Chief Operating Officer (COO)
Scott Pierce
Give 8 step call strategy?
Acknowledgment
"I CAN" statement
Transition to probe
Probe (issue/validation)
Solutions w/ options
Gain Acceptance
Recap
Ask "is there anything else?"
Member has FULLY INSURED policy. She wants a copy of EOC. What options can be given to fulfill requests?
1. obtain from group
2. access member portal
3. agent order a paper EOC for the member