A LITTLE BIT OF EVERYTHING
EVERYTHING RX
EVERYTHING DME
HOLD EVERYTHING
EVERYTHING SITUATIONAL
100
Which auxiliary persons must be changed yearly?
AR
POA Stays
100
If a member pays $0.00 for generic and brand named medications and also, have a 0.00 deductible, what level of LIS do they have?
LIS 3
100
A member calls in needing a new walker. What is the process for DME that you would advise the member on?
PA from dr to INN DME> then INN DME puts in PA to UHC> approve or disapprove and DME releases equipment
100
What if a member asks you to hold on for a minute?
There are a number of reasons a caller may ask you to hold. Those examples may include, but are not limited to:
- Getting their medication bottles
- Getting their credit card or checkbook to make a payment
- Answering the door
- Answering another call
If a caller asks you to hold, offer schedule a call back if the expected time may be over ten minutes.
- Offer schedule a call back if the expected time may be over 10 minutes.
- You must remain on the line until they return to the call once you agree to remain on the line when a caller requests you remain on the line for over 10 minutes.
- There is no maximum hold time in these situations.
- Reach out to your Supervisor for guidance if there has been no response within 15 minutes.
- Review the following job aids for guidance with regard to remaining on the line:
- Disconnected Call Process
- Schedule Commitment Process.
- Disconnected Call Process
100
When you have dead air and cannot communicate with member what is your verbiage?
Follow the standard greeting and pause for a few seconds (not to exceed 10 seconds). When there is no response, or there is only a dial tone or dead air:
- State the greeting a second time.
- Pause for a few seconds (not to exceed 10 seconds).
- Did the caller respond?
Yes: Address the caller's questions and concerns.
No: Suggested Scripting for:Inbound: "I'm sorry, but I cannot hear you. If you can hear me, please hang up and call back at the same number you just dialed. Thank you for calling UnitedHealthcare. I am now releasing the call."
Outbound/IVR: "I'm sorry, but I cannot hear you. If you can hear me, please hang up and call back at PDP/MAPD Collections Callback Number>. We are available Monday through Friday from 8 am – 6:30 PM CST. I am now releasing the call."
200
Can a POA add an eligible family member as an AR to the member's account?
Yes, but remember that it is the relationship to the member that must be eligible, not the relationship to the POA.
200
When does the formulary change?
Formulary changes including tier status changes resulting in higher copayments of maintenance medications occur 2-3 times per contract or plan year. Tier changes that result in a lower copayment may occur at any time. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage and lower-cost options.
200
What job aid do you find the National DME list?
DME Vendor Website Look Up - Index (KM1004252)
200
How do you place a caller on hold?
- Explain why you need to place the caller on hold
- Ask caller for permission to be placed on hold
- Advise caller how long the hold time will be
- Return to the caller before the timeframe given expires
- Express appreciation or acknowledgement for the hold
- If necessary, request additional hold time
200
What if you have an unresponsive caller what is your verbiage?
- Address the caller.
- Wait 10 seconds for a response from the caller.
- Continue to address the caller and wait an additional 10 seconds for a response.
- Did the caller respond?
Yes: Address the caller's questions and concerns.
No: Suggested Scripting: "I'm sorry, but I cannot hear you. If you can hear me, please hang up and call back at <PDP/MAPD Collections Callback Number>. We are available Monday through Friday from 8 am – 6:30 PM CST. I am now releasing the call."
300
What is included in a Welcome Kit?
Pre enrollment materials
Post Enrollment materials
ANOC
Id cards
Timing
Questions
300
Period after the member has met the True Out of Pocket (TrOOP) cost for the benefit year. Once this amount is met, the plan resumes coverage.
Catastrophic Coverage
300
What are the three recommended DMEs for CGMS?
Byrun
Edgepark
Adaptahealth
300
What do you do if caller doesn't want to be placed on hold?
Suggested Script: What I can do is connect you directly with an agent who will get your issue regarding [state caller's issue] resolved. You may hear some silence or music during the conference process. I will stay on the call with you to ensure your issue is resolved.
300
You receive a one breath call what are some key points to handle this call?
Do not place the caller on hold.
- Ask probing questions to be sure you heard the allegations correctly or to clarify the caller's intentions.
Example: "I'm concerned I may not have heard you correctly. Did you say you will attempt to harm yourself?"
- Ask the caller to please be patient and remain on the phone to discuss the situation.
- Listen carefully and advise the caller that help is available and offer to personally assist in obtaining that help
- Mute the call and ask your Supervisor for immediate assistance.
400
What is the TAT for a Par Provider Claim?
* Initial Processing: 30-60 calendar days
* Reworked Claims: 30 calendar days
* Additional Info Submitted: 60-calendar days from the date and info is received
* Reconsideration: 30 calendar days
Job Aid: Claims Codes and ICES - Claim Processing Turnaround Times (KM1005728)
400
Period between the member meeting the Initial Coverage Limit and prior to meeting True Out of Pocket (TrOOP) cost. In this level of coverage, the member is responsible for a percentage of their drug costs.
Coverage Gap
400
What resources can you use to find an INN DME?
National DME list or RALLY
400
What if hold time is longer than 5 min?
- Offer the caller the choice to continue to hold or schedule a follow up if the hold time will be longer than 5 minutes:
- Phone: Refer to the Schedule a Commitment Process to follow up with member over the phone.
- Email: Refer to the Secure Email Process to follow up with the member through email.
- Phone: Refer to the Schedule a Commitment Process
400
What are your 5 Ws in probing questions?
Who
What
When
Why
Where
500
What is the UBH (Behavioral Health) address for COSMOS claims?
P.O. Box 30757
Salt Lake City, UT 84130-0757
Job Aid: Claims Addresses - COSMOS (KM1005958)
500
A member calls about the order status of a prescription for home delivery. What options does the member have for checking the status of their order?
1. Online at OptumRX website if member has registered.
2. By phone
Job Aid: Home Delivery Pharmacy - Check Order Status (KM1007497)
500
Are CGMS covered under DME or Part B?
CMGs and their components are covered uner the Medicare Part B Diabetic Monitoring Supplies benefit and cost share but must be supplied by a DME provider.
Job Aid: Benefit Coverage - Continuous Glucose Monitors (CGMs) (KM1004326)
500
When coming off hold with member what do you say?
Reconnect with the caller to express appreciation or acknowledgement for being on hold.
Examples may include, but are not limited to:
- Thank you…
- I apologize…
- I appreciate…
500
When needing to escalate to a supervisor, how do you transfer to a navigator if member would like that?
Nav4me