Benefits
Member's should be connected/transferred here to verify their INN specialty pharmacy and cost shares for specialty self-administered medications
What is Flex Access and Advocate+ Pharmacy Match
This is required to be documented in the comments section of any calls related to the OOS SUD (Out-of-State Substance Use Disorder) Claims
What is #1157
The following statement is True/False:
Cleveland Clinic is OON with Florida Blue as of 03/01/2026
What is False; Cleveland Clinic is INN still after recent negotiations; check provider connect for PAR status
Respond to this inquiry:
"I'm new to Florida Blue and I see my PCP is not the current assigned PCP showing on my account. I had to cancel my appt today and reschedule one for next month. I want to make sure this is updated before my next appt. Can you update for me please?"
What is (Acknowledge emotion and offer self service)
*Welcome to Florida Blue! Sorry for any inconvenience you experienced with the incorrect PCP being assigned but I'd be more than happy to assist you with updating your PCP. Do you have a moment to log in to your online account so I can further assist you with the update? (provide navigation steps)
The following statement is True/False: The Home Health Care benefit applies when members have an At Home Sleep Study test done.
What is False; The benefit is based on the POS of the treating facility on the prior authorization (ie., OP Hospital or Independent Testing/Sleep Study Center)
Common error codes for MWS log in issues can be found in this section of this procedure; The procedure If troubleshooting does not resolve the issue
What is Assisting Members with Log In issues of Prod 2366; Reach out to Senior for assistance
The program that launched on 2/6/26, displaying discounted drug pricing for approximately 40 prescription medications, providing drug manufacturer financial assistance to consumers.
What is Trump Rx
Respond to this inquiry:
I think I sprained my wrist while on vacation and I need to seek urgent care or go to emergency room as I'm now experiencing a lot of pain. What's facilities can I go to INN and what's my benefits?
What is (Acknowledge issue/emotion and offer to walk through self service)
*So sorry to hear about your injury and the pain you are experiencing. I know that must be very uncomfortable for you. I can definitely assist you with locating your benefits and an INN provider online. Are you able to log into your account at this time? (provide navigation steps)
Prior authorizations for Self-Administered specialty rx are required to be submitted through __; Prior authorizations for Medical Pharmacy (Provider Administered Specialty) are required to be submitted through ___
What is Prime (covermymeds.com); Medical Pharmacy Solutions via Availity (gatewaypa.com)
The required process for handling and documenting repeat callers
What is
1. Ask if the member has already called about the issue
2. Look for tasks related to same issue in past 4-8 days
3. Check repeat caller box and add related cases
4. Fill out "Task Attributes" section
5. Manually document task notes in PAR format
These two centers with this billing group are back in network with Florida Blue effective 03/01/26.
What is Cypress Creek OP Surgical center & South Broward Endoscopy with Memorial Healthcare
Respond to this inquiry:
I've been trying to make a premium payment for my daughters policy and I'm having a really hard time logging into her online account. Can you just take the payment for me over the phone?
What is (Acknowledge issue/emotion and offer self service)
I certainly understand your frustration with trying to log in to your daughter's account. We actually have a option for you to make a guest payment for one of our member's that doesn't require you to log in. Do you still have our website pulled up? I can walk you through how to make a guest payment. (Provide navigation steps)
For BVC Technical issues with registration, accessing BVC services, or other error messages, reach out to __ for Support; Issues with appointment scheduling, payment issues, & live visit or post visit issues, reach out to ___ for Support
What is Florida Blue (Senior Advisor) and BVC Amwell Support
The pathway to validate Better You Rewards Adjustments in ME (Member's edge) (ex.,# 75186219); Line of business that is excluded from rewards program eff 01/01/26
What is (one of the two pathways in ME to see BYR adjustment) Invoice Summary or Invoice Adjustments; Group policies and Buy-up groups
Effective 1/1/26, Sleep Study related prior authorizations are managed by __
Florida Blue via Availity
Respond to this inquiry:
My doctor submitted an appeal for my medication Mounjaro that you guys denied. I already spoke with Prime and have been transferred all around today. I just need to know the status of my appeal.
What is (Acknowledging issue/emotion and offer self service) I'm sorry for the experience you've had trying to get assistance and I get how important it is to get the status of this appeal for your denied medication. I'd be more than happy to help you review the status of your appeals on file, do you have a moment to log in to your online account? (Provide navigation steps)
Benefits that are extended for women wellness screenings effective 01/01/26
What is $0 expanded screening coverage only applies to women ages 40 yrs and over; medical cost share applies for women under 40 yrs. Additional imaging (such as MRI, ultrasound, or additional mammography) and pathology evaluation (i.e., breast biopsies) that may be necessary to complete the screening process or to investigate findings on the initial screening mammography will be covered 100%. (Must still be billed with appropriate routine codes)
Outline the guardian role registration process from start to finish (Hint. about 5 steps )
What is the following steps:
1. Service Advocates are responsible for entering the guardians demographic information into PDI2 tool under the Child only account.
2. The member will receive an email in 24-48hrs instructing them to submit proof of guardianship (Birth certificate & DL; Legal Guardianship documents)
3. Documents submitted should be submitted to CRS for approval
4. Guardian will receive email invitation to register once documents are approved by CRS
5. Guardian can complete registration
The process to request a copy of the OOS SUD letter and eligibility verification form be resent to the member at an alternate address.
What is advise the member they must send request in writing; still send task to appropriate area per prod
Respond to this inquiry:
"I'm having an extremely hard time submitting a claim on your MWS. I am submitting about 30 pages of supporting documentation and it's telling me the file is too large. How can I submit this claim?"
What is (Acknowledge issue/emotion and offer self service; options for solution)
*Sorry to hear you're having such a hard time trying to submit your claim. I'd be more than happy to help you get that claim submitted through the message center on you website account. Have you tried minimizing the file by separating it into a few documents per file? If you submit multiple documents on one message indicating they are for the same claim, we can combine them for you. (provide navigation steps)