UHC Basics
What does UHC stand for?
UnitedHealthcare
What is the standard greeting used by Optum customer service advocate?
Thank you for calling UnitedHealthcare , this is _______ may I know please if I'm speaking to ______ ?
What do you check first when a member asks if something is covered?
Evidence of Coverage / RMB
What denial occurs when the doctor is not in network?
Out‑of‑network denial.
What should you do if a member says their bill looks wrong
Review claim + benefits with them.
What intent do advocates use to view member benefits?
Review Medical Benefits / Evidence of Coverage
What should an advocate do before releasing account information?
Complete HIPAA verification
What do you call the set amount a member pays per doctor visit?
Copay
What is the common fix if the provider billed incorrect information?
Provider must submit a corrected claim.
What is the right response when a caller is upset?
Empathize, reassure, and provide solutions.
What is the term for the amount a member pays each month to maintain coverage?
Premium
What tool is commonly used to document calls?
Maestro
What is the percentage the member pays after deductible?
Coinsurance
What is needed when a claim denies due to coordination of benefits?
Updated COB from the member.
What should you advise when the provider billed wrong units?
Ask provider to resend corrected claim.
What number on the Ucard is used to verify eligibility?
Member ID
What is the correct action when unsure about a policy?
Check job aids or ask support/SME.
What document shows how a claim processed?
Explanation of Benefits (EOB).
What should a member request when needing detailed claim info?
A copy of the EOB.
What do you explain when a caller changed insurance but gets old claims?
Dates of service vs. coverage dates.
What system is used to check provider information?
Search and assign intent / Provider Lookup tools.
What metric measures if an agent resolves the issue in one call?
First Call Resolution (FCR36).
What term refers to the limit by which claims must be filed?
Timely filing
What internal team handles complex claim disputes?
Claims Research / Escalation team. ( tier 2 / 3 )
What is the proper action when the case needs approval beyond agent scope?
Escalate to TL/Senior Specialist.