Category and Intent
Account Summary
Situational Guidelines
Medicare
Part D
100
Amy Calls. She needs help locating an in-network pharmacy. You locate her account in MIIM. Which category will you look at to find the "FIND A PHARMACY" intent?
Pharmacy
100
When do you launch Account Summary?
When MIIM Prompts you to "launch account summary"
100
How much call silence is appropriate before you should consider placing the member on hold?
60 seconds
100
To purchase a Medicare Advantage Plan a member must already have???
Medicare part A and Medicare part B
100
During what phase does of a Part D plan does a member pay 100% towards the cost of the medications?
Deductible
200
Ashley has a question about a bill she recieved from her doctor. What category and intent do we need to use to answer her question?
Claim Category - Review Claim History Intent
200
Mrs. Smith calls. She wants to know about her premium payment. What tab in Account Summary would we access to find this information?
Billing Tab
200
What is Call Avoidance? What are some examples?
Call Avoidance - Any method used to avoid taking calls from our members. Ex. • Manipulation of aux codes which impacts routing or receipt of calls. • Leaving your immediate work area while your phone is in an “available” state. • Failure to wear your “head set” at your desk while in an “available” state. • Failure to respond to a caller when connected with the call; which results in the caller disconnecting the call. • Inappropriate disconnection or release of phone calls prior to completing the phone call. • Placing a caller on hold/mute to tend to personal/non work related activity. • Usage of inappropriate language/tone. • Placement or receipt of inbound/outbound personal calls during avail time.
200
2)OPP Which of these are not a Medicare Advantage Network Type? 1) HMO 2)OPP 3)PFFS 4)SNP
2)OPP
200
What does the member pay during the Initial Coverage phase?
The member pays their COPAY or COINSURANCE
300
Ginger calls. We have located her account in MIIM. She would like to know who the pcp in her area are and change her pcp. What two categories would we look at?
Member Category - Search provider Intent Plan Category - Update PCP Intent
300
Barbara calls. In order to answer her question, you need some specific information about her medicare status. Which tab in Account Summary has this information?
Eligibility Tab
300
What should you "hit" for warm transfers?
The objective is to: • Explain the need to TRANSFER the customer • Ask the customer for permission • Inform the customer what you will do • Explain how long it will take
300
Which of these is NOT included in Original Medicare? 1) Part A 2) Part B 3) Part C 4) Part D
3) Part C 4) Part D
300
Who pays the most during the catastrophic coverage phase?
The plan ~95%
400
What are the Eleven Intents in the PLAN category?
1.Coverage Determination Status 2.Review Medical Benefits 3.Educate DMR 4.Review Rx Benefits 5.Manage a Rider 6.Update Member COB 7.Manage Passport 8.Update Member LIS 9.Organization Determination Status 10.Update PCP 11.Review Mail Order Status
400
Sam calls. In order to answer his question, you need to research his Part D benefits. Which tab in Account Summary has this information?
Benefits tab! extra: under the Pharmacy benefits!
400
There may be times that a call is received, but there is no response from the caller (empty line). What do you do?
"1. When there is no response to the standard greeting, state the greeting a second time." "2. If there is no response wait 10 seconds for a response from the caller. If there is still no response, then state: “I’m sorry but I cannot hear you. If you can hear me, please hang up and redial the 1-800 number you originally dialed. Thank you for calling UnitedHealthcare. I am now releasing the call.”"
400
Mabel is having problems with her Medicare plan. She files a complaint about the health plan with Center for Medicare and Medicaid Services. What is this complaint called? Options are: 1) Appeal 2) CTM Case 3) Official medicare Complaint 4) Verbal Grievance
2) CTM Case
400
Luke is trying to remember what begins after the member (if applicable) and the plan together have met the Total Drug Spend. What do you tell him?
Coverage Gap
500
Jerry calls. He had a bad experience with another ccp and he wants to file an official complaint. You locate his account in MIIM. Which category will you look at to find the "COMPLAINTS, APPEALS, AND GRIEVANCES" Intent?
Member
500
What are all the tabs in account summary and what are they for?
Dashboard - High level Overview Summary - More in depth Overview *Only place you can find member's pcp Member Info - view, update or add account information about the member. Eligibility - reference information regarding the member's account such as LIS or Medicaid. Benefits - high-level overview of the member's benefit information such as copay and vendor. Claims - View claims from providers and hospitals. Provider - SEARCH for in and out of network providers. Billing - provides a current glance at the member's premuim information. Reference this section when the member asks questions surrounding his/her current premium due, amount past due, etc. Enrollment - view a member's application information. Fulfillment - Send materials to member. two types of fulfillment know as marketing materials and non-marketing materials. Non-marketing materials are member or plan specific materials. Items that we send to a member are referred to as fulfillment. Notifications - notification is a provider notifying the plan that a procedure has been or is going to be performed.
500
What do you do if a member asks for your full name?
CCPs are only required to provide their first name when assisting callers. In the event a caller requests the CCP’s full name/last name, CCPs should state the following: "For privacy policy reasons I am not allowed to provide my last name. However, I can provide you my five-digit agent ID as a reference for this conversation". [Provide agent ID to caller]. Please note: • The five-digit agent ID is also commonly referred to as your Avaya ID, VCCD ID, or IEX ID. • If a caller is referencing an agent ID from a previous call, you should include the agent ID in your documentation.
500
Medicare Supplement plans may cover additional benefits not offered by Medicare. Which of the following are NOT covered by Medicare Supplement Plans? Please select all that apply: 1) Dental 2) DME 3) Long term Care 4) RX Drugs 5) Vision
1) Dental 3) Long term Care 4) RX Drugs 5) Vision
500
What are some methods that we have to aid members in the coverage gap phase?
• Explore national community- based charitable programs. "• Look into State Pharmaceutical Assistance Programs- http://www.medicare.gov/pharmaceutical-assistance-program/state- programs.aspx" "• Check Pharmaceutical Patient Assistance Programs to see if your drugs would be covered by the manufacturer. Some manufacturers provide medications to people who express that they need help to purchase them. (Income restrictions apply. A separate application is required.) http://www. medicare.gov/pharmaceutical-assistance-program/index.aspx" "• Apply for extra help from the Social Security Administration. "
M
e
n
u