Process Task
Plan is terminated
Process it as All Good
This is where we escalate to when Specialty Pharmacy and BB is not available
Supervisor
We will say we are calling as the member if given the option for this payer in the IVR
UMR(800-207-3172)
This particular payer agents state they no longer quote benefits for part B drug and we must obtain it from CVS. How to continue with the call?
Its Humana, we Marks Yes for J code Valid and Billable, HS Copay, Co Insurance and continue the call.
Agent provides different member ID than what we have on file
Representative provided updated member ID: XXXXX.
Payer agent advises they are unable to provide benefits due to us having missing HIPAA information about the patient or the provider/practice.
Requeue for: Missing Input Information
If the agent mentions they already spoke with their Supervisor, this is what can be done
Follow the above guidance of submitting as complete with task note & escalation box unchecked.
We prompt "Don't have it" even though we have the NPI for this
Wellcare Medicare
Is there a Copay or Coinsurance for the J code 2777?
Yes, Between 50$-150$. What is the next PB and how do we continue the call?
If for the J code:
What is the coinsurance percentage?
Enter coinsurance if provided for the J code.
Otherwise enter the highest copay.
Whenever an agent states the plan is handled by a third party/separate department.
Plan administered by separate department.
Payer agent states that benefits have already been obtained, and they are unable to provide benefits again.
Requeue for: Representative will not reverify benefits
This is what needs to be done when the agent advises us to talk to another dept for Buy and Bill question and it's not the supervisor who can tell us the answer.
If the agent offers to transfer to another department:
we should take the transfer.
Benefit details, Injection, Office Visit, When it asks for fax number, ignore. Prompt "Benefits." It will ask if we don't know the fax & we can say yes here. Customer Advocate. Are these the steps to drive IVR for Blue Cross & Blue Shield of Rhode Island?
Yes, refer to Driving IVR tab line 58-63
We GE the call and process it as "Unreliable agent" when the agent states the Codes are covered at 100% even after PB when the OOP Max is met in full.
No,
If still 100% Input:
Valid & Billable: Yes.
Coinsurance: No.
Copay: No.
Add TN. Continue the call.
Agent could not provide original benefit structure
Representative could not provide original benefit structure; services covered at 100% since out of pocket is met.
Payer agent advises they are unable to provide benefits due to us having incorrect HIPAA information about the patient or the provider/practice.
Requeue for: Incorrect Input Information
PA dept cannot locate the member after escalation and informs the member's plan is terminated.
After 1 unsuccessful attempt, if we cannot get the needed information from the agent:
Submit the with the benefits call as complete & Escalation Box ticked.
This is the information we prompt thrice for a specific payer in the IVR
Prompt Tax IS (3X) for Georgia Medicaid
When asked for the admin code benefits agent states they no longer provide cost share for the admin codes and will have to obtain from the website. This is what we do..
If an agent cannot provide cost share:
Valid & Billable: Yes.
Admin Code Cost Share: Headset.
Continue the call.
(C/S line 36)
Agent asks us to refer website/medical policy for ST requirement( ONLY FOR BCBS CALLS)
Refer to medical policy for step therapy.
Eva on autopilot incorrectly navigates the IVR or if Eva responds incorrectly to the agent leaving questions unanswered or ambiguous information was provided without pushback.
Requeue for: Eva Autopilot Error
PBV shows active PA with start date: 01/01/2024 and end date: 01/01/2026 for the same J code, DX code and the same provider.
Agent on the call gives us an Approved active PA on file with start date: 01/01/2025 and the end date: 12/31/2025 for the same J code, DX code and the same Provider.
Escalate to the PA department to confirm this information and take whatever the PA dept agent provides.
Regardless the member ID we have on the platform, We Enter the following member ID: ABC,1,2,3,4,5,6,7,8,9 and Confirm that it is correct for this payer
BlueCross BlueShield of Tennessee
This is when we collect Admin and SOV benefits even when the J code is not covered.
When The J code is not covered it goes through a PBM Pharmacy Benefit Manager.
If NO PBV:
J code Valid & Billable : No.
Why not covered? No RX Benefits - drug covered under PBM. Continue the call & collect Admin & SOV/HOV benefits. Obtain reference number, GE, & add TN.
Agent provides cost share information for multiple tiers and can not determine which tier applies
Plan has multiple tiers. $X/$X/$X for the product, $X/$X/$X for the administration, $X/$X/$X for the specialist office visit.