Carlyncia' s Team Jeopardy (April'24)

HIPAA/ Authentication

100

What are the four authenticators?

Member's first name and Last Name, member's DOB, Member ID, ZIP CODE

200

How do you answer CMS Test Call?  

Always answer “Yes I can” when asked if you can assist.

300

True or false Third party callers can change account phone numbers, add or remove current payment methods and request a override 

What WI will you will find this information? 

FALSE: 

No changes to the account can be made by the caller.

Examples of account-level changes include the changing vital details on an account:

• Phone number
• Address (includes temporary address)
• Email address
• Assist with Caremark.com
• Add or remove current payment methods.
• Assist with any medication the caller did not first tell you the name/Rx number.
• Place Hold, Cancel, Discontinue an order (Prescription (Rx)).
• Request Plan Benefit Override (PBO).

Please refer to: 

Content ID : CMS-2-028920

HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS

400

True or false We can provided the member ID number to members ONLY 

False 

 Do not provide the effective dates and/or the member ID* for the member’s account.

500

What is the next step after obtaining the member's First and Last name for a authenticated caller? 

Ask "Are you calling for yourself today" 

Please refer to:

Content ID : CMS-2-004568

Universal Medicare D - Caller Authentication

CCF(Call Flow)

100

True of False: we must answer the call within 3 seconds 

True! Per LOB guidelines Answer within three seconds 

200

• Prescription Name
• Prescription Number
• MED D Only: MBI
• Plan Sponsor

What is Secondary Authenticators ?

300

3 or more calls within seven consecutive days for the same issue Or you recognize from the Notes or View Activity has a history of calling on the same issue that remains unresolved regardless of the time period…

what is a procedural Senior team transfer? 

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

 Warm transfer to the Senior Team

 Reminder:  Log the call as a Transfer. 

 Add Notes: Include one of the following keywords:  Repeat, Multiple, or Unresolved Issue.

400

what needs to be pulled up on every call? 

The Source 

Utilize theSource and PeopleSafe/Compass on every call. For each situation you should review the work instruction specific to the scenario at hand. If UNABLE to resolve the issue and you have utilized all resources (team chat, supervisor, team SME), inform the member that you would like to reach out to the Senior Team for assistance and to ensure an accurate resolution.

 

500

After resolving the issue: Provide solutions, alternatives, and additional options 

What do you do next? 

Hint: 3 answers 

1.RECAP! 

Recap the call.

• Include why the member called
• The information you provided to the caller
• What was done for the member and the turnaround time (i.e., New RX Request, EPA request, etc.).

2. Closing with the appropriate closing 

"Thank you for calling. It’s been a pleasure speaking with you, have a great day!"

3. Documenting the Call:

• 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:
• Result:

Order Placement

100

Step one for a prescription refill  

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

200

True or false:  If speaking with A 3rd party, they must provide the last four digits of the credit card and expiration date or say “use default card” to complete the order, along with the member address and phone number. 

TRUE!

300

Please keep in mind that the amount due for your order may vary from this quote upon processing.

What is the price disclaimer? 

400

What is the TAT for when the order is expected to ship? 

• Prescription refills with no issues (not expired or out of refills) ship within two business days after order is placed/received.
• New prescriptions ship within 5 business days after order is placed/received

500

What all do you need to recap in the  Refill Snapshot screen including the member's name. 

Hint: 

Content ID : CMS-2-004628 Prescription (Rx) Refill/Renewal (Order Placement)

• Drug Name
• Strength
• Available Fills
• Quantity
• Days’ Supply
• Formulation (Examples: Tab, capsule, ER, or extended release, etc.)

coverage determination

100

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. 

200

Standard request decision 

 Decision within 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

who can start or check the status of a coverage determination or a redetermination? 

Before beginning the process or checking the status of a Coverage Determination or Redetermination, the CCRs MUST verify they are speaking to one of the following individuals:

• Beneficiary
• Authenticated SHIP Counselor
• Physician or other Prescriber (includes representative of a prescriber's office or a representative of the prescriber)
• Power of Attorney (POA) or Appointed Representative (AOR)

400

True or false: 

Only file a First Call Resolution Grievance for plan design issues or for issues with the Coverage Determination process.

TRUE

500

When do you transfer to senior team in regards to coverage determinations? 

• Beneficiary is escalated and insistent on being transferred to the CD&A Team
• Case Notes indicate to contact the CD&A Team for more information on the request
• Beneficiary calls with approval on file, but medication still rejecting at the pharmacy
• Beneficiary wants to withdraw a case that is open or pending
• Beneficiary calls with a change in provider/prescriber for an in-progress case
• Beneficiary returning outbound call from CD&A Team
• Client Representative/Benefit Office wants to speak to CD&A on behalf of the beneficiary

Grievance

100

After you determine that the caller is expressing dissatisfaction what do you do? 

• First, determine if the Grievance is handled by CVS or the Client. Refer to the CIF to determine if the Client has contracted with CVS Caremark to handle its MED D Grievances.

200

who is authorized to file a Grievance? 

Before beginning the Grievance process, CCRs MUST verify they are speaking to the beneficiary, SHIP Counselor, an Appointed Representative, or the Power of Attorney.

300

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

400

True or False 

If another grievance is submitted for the same category that is closed we should file a new one 

TRUE! 

• If the previous Grievance is closed/resolved, file a new Grievance.

• 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 [e-mail] 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

When a Grievance is handled by the Client, what verbiage should be used since a Grievance cannot be offered?

Inform the beneficiary the issue is handled by the Client and warm transfer the call so the issue can be resolved.