Closed Claim Rate
This is the percentage goal for our team to meet for closed claim rate metric
What is 5% or higher
This NBA is presented to encourage members to see their PCP for their yearly visit to discuss their overall health and any gaps in care with preventative health
What is the Annual Wellness Visit NBA?
Best practices to encourage members to complete the Flu shot NBA
Educate member on rewards. Assist with locating an INN pharmacy. Educate on the benefits of receiving the flu shot. Encourage members to speak with their PCP when members refuse.
What are the three medical conditions that may prompt you to address the med adherence NBA?
hypertension ; Hypocholesteremia (cholesterol) ; diabetes
This site should be utilized when member advises of a need when addressing the SDOH and/or Unmet Social Need NBA
What is FindHelp?
These NBAs, when completed, will have an attached claim which goes toward the closed claim rate percentage
What is the Annual Wellness Visit / Medication Adherence / Flu Shot / Care Coordination / DSNP No PCP Assigned
This NBA notifies when a member does not have an assigned PCP and is meant to encourage member to find a PCP and address gaps in care
What is the DSNP No PCP Assigned NBA?
This is the percentage goal for the NBA Acceptance Rate metric
What is 60% or higher?
This NBA addresses gaps in care with receiving medication by providing member with a 90-day medication refill option and/or home delivery for cost savings and convenience.
What is 30 Day to 90 Day Refill and Home Delivery NBA?
This site should be used to locate a PCP and/or Pharmacy if member needs assistance with finding a provider when addressing NBAs such as AWV, DSNP No PCP Assigned, and Flu Shot
What is Rally site for provider search?
When a member states they prefer to schedule on their own, what are some best practices to take ownership?
This is the percentage goal for PCP Engagement Metric
What is 80% or higher?
This information within NBAs provides details and goal of the NBA along with a flow chart to follow to encourage member completion
What is scripting within NBAs?
This NBA goal is to inform members about new benefits coming their way with their plan in 2024 along with Food/OTC benefit and $0 Prescription Drugs
What is DSNP ANOC Good News -
Food Card, OTC and $0 Prescription Drugs?
What is Pharmacy Claims intent?
Best practices that will help improve closed claim rate metric
What is schedule follow ups for member check in and check for claim on file when member states already completed?
The goal of this NBA is to verify with member if they have an assigned PCP, and if so, if their pcp is up-to-date about the care they have received from a specialist or ER/Urgent care visit. Navigators should assist with scheduling check in appointment with pcp if they have not seen their pcp since the er/urgent care visit
What is the Care Coordination CAHPS NBA?
Best practices to follow when addressing Housecalls NBA
Educate member on housecalls vs AWV (when applicable). Educate member on the virtual visit option if member express discomfort with stranger in their home. Provide the Housecalls scheduling phone number if members refuse. Educate on rewards.
This NBA Informs members they are eligible for the Medication Therapy Management Program and offers to assist the member by scheduling an appointment or transferring to a pharmacist.
What is the Comprehensive Medication Review NBA?
This SOP reviews all DSNP NBAs and provides guidance to specific SOPs for each NBA in order to address with members correctly
What is the Maestro Next Best Actions (DSNP) SOP?
Member states they already completed their AWV. What are best practices to follow in this scenario?
Confirm AWV claim on file under correct coding within the Review Medical Claims Intent via Maestro. Call PCP to confirm AWV date.
What are some talking points to follow to encourage member to complete their AWV?
Educate member on rewards. Educate members on the importance of preventative care.
Best practices to encourage members to opt in for text and/or emails when addressing the DSNP New Member Digital Adoption
Utilize the talking points to educate member on the full benefits of going paperless and/or receiving text messages directly to their mobile phone.
The goal of this NBA is to educate members and attempt to schedule a Colonoscopy and/or send iFOBT kit to members home
What is Colorectal Cancer Screening NBA?
What resource should you utilize to locate the acceptable reasons to not address an NBA?
A4Me - Reasons to Not Present a NBA SOP