Show:
HIPAA/Authentication
Grievances
Coverage Determination
Order Placement
Consultative Call Flow (CCF)
100

The four authenticators for a NOT CTI/IVR call

First and last name

Date of birth

Member ID

Zip Code

100

The first step after you have identified a grievance

Check the CIF to determine who handles the grievance type for the plan

100

What you must do if you run a test claim and receive this reject code: Prior Authorization (Reject 75)

Peoplesafe users: Create a CD&A RM Task 

Compass users: Manually submit a Med D CD&A Support Task as needed.

100

The first step in placing a refill order

Ask the member how many days’ supply of medication they have on hand

100

The amount of seconds you have to answer the call

3 seconds

200

The correct way to answer a call for a plan that does NOT have a specific greeting (i.e. FEP MPDP or Indiana University Health plans)

Thank you for calling. My name is ______. Who am I speaking with?

200
The person or persons that are authorized to file a grievance

Beneficiary

Power of Attorney (POA) or legal representative (guardian) for the beneficiary

Appointed Representative (AOR) (includes a Provider/Prescriber)

SHIP counselor

Informal authorized 3rd party

200

The first thing you should do when completing a coverage determination

Refer to the appropriate CIF to determine who handles Coverage Determinations for the plan

200

What you are required to say to the member after providing their copay amount

The copay disclaimer: "Please keep in mind that the amount due for your order may vary from this quote upon processing"

200

The four secondary authenticators

Prescription name

Prescription number

MBI

Plan sponsor

300

The question you should ask every caller during authentication (unless it is an internal transfer that has already been fully authenticated)

Are you calling for yourself today?

300

The time limits for filing a grievance

60 Days!!

“An enrollee may file a grievance with the Part D plan sponsor either orally or in writing no later than 60 days after the event or incident that precipitates the grievance.”

Therefore, if the elapsed time between the date of the event (or occurrence) and the date of reporting the Grievance is greater than 60 days, a Grievance should NOT be opened.

  • Instead, the CCR should continue to work the issue until resolved without filing a grievance.

Note:  If the event date is open to interpretation, choose the most recent reasonable date.

300
The timeframe for a standard coverage determination

Up to 72 hours from date/time of receipt of valid request, but exception requests may be up to 408 hours (17 days) if a statement of medical necessity is needed from the Prescriber.

  • This includes nights, weekends and holidays
300

The TAT statement for a RX that has refills remaining and is not expired

You can expect your order to ship from our pharmacy within two business days. Monday through Friday are considered business days, although mail order is open every day

300

The only required question to ask on an internal transfer call

Has the caller been fully authenticated?

400

The question you should ask only to third parties

Is the beneficiary aware that you are calling for them today?

400

For an open/new grievance, the next step after documenting the grievance in PeopleSafe with detailed notes

Contact the Senior Escalation Line to provide the reasoning to file a Grievance in PeopleSafe to obtain permission

400

Some of the words/phrases that indicate a request should be expedited instead of standard

  • Patient is out of medication.
  • Patient will be hospitalized or die if they do not receive the medication.
  • Need medication in 24 hours or today/tomorrow
  • Expedite
  • Urgent
  • Immediate
  • Stat
  • Emergency
  • Exigent
400

The 4 pieces of information that a third party must provide in order to be able to place a refill order

Medication name

Delivery address

Member phone number

Last 4 digits of CC# or just say "use default card"

400

The exact statement you should say to a caller that has called 3 or more times within 7 consecutive days for the same issue or who has a history of calling for the same issue that remains unresolved

Please allow me to transfer you to our Senior Team who can provide further support. May I place you on a brief hold?”

500

The person or persons that can update an address/telephone number/email address

The member

Legal representative (POA, legal guardian, legal conservator)

500

After checking the CIF to ensure Caremark handles the grievance, and after making sure that the caller is authorized to file a grievance, your next step should be

Always check PeopleSafe for existing Grievances!!

  • DO NOT enter another Grievance for the same Category if the Grievance is still open.
    • If there is an open/in-progress Grievance, educate the member that the issue has been filed and advise of TAT.
    • If there is an open Grievance and another Grievance in the same Category occurs, notate the account and send email to DelegatedGrievance@CVSHealth.com and CC your supervisor
      • It is the Category that determines the Grievance, not the subcategory.
    • If the previous Grievance is closed/resolved, file a new Grievance.
500

The mandatory step that is required to be performed for all coverage determinations to confirm accuracy

Repeat the entire request back to the caller

500

What you must do if a member has a $0 copay, no payment method on file, and the "save order" tab is NOT present

Submit a manual refill request RM Task

500

The 3 parts of call documentation

  • Reason:
    • Who called is vital to ensure HIPAA compliance as well as compliance regarding AOR or POA.
    • What the caller is calling about/What the issue is.
    • Where the problem exists (Example: Mail order, point of sale, etc.).
    • When the issue occurred or is anticipated (in the past or future date).
    • Why it is an issue for the beneficiary/Why it should be resolved.
  • Action:
    • What happened?
    • Notate what actions you took during the call. (RM Task created, was the member transferred?)
  • Result:
    • End result?
    • Notate actions taken to resolve the call
    • Notate what you did next if the issue was not resolved.
      • Example: Transferring call to another department? If so, notate that in the Result.