Systems
If you are needing to transfer your notes to your supervisor, what system are you using?
Callnotes
A member is calling in stating that her claim is denying due to needing a accident injury form what do you advise?
Let the member know that we can take the form over the phone and send the information up so their claim can be reviewed.
If a claim processed 3 weeks ago and the provider is stating that the claim is underpaid what do you advise?
They would have to appeal the claim if they are stating they are underpaid.
Who receives a EOB?
Members
If a broker is calling in about their commissions, who do they need to speak to or be transferred to?
Broker services/Business development.
If you are needing to verify a pay to address for a provider, what system are you using?
Meditrac
a 18 year old dependent (003) on their mom's (001) policy- No phi on file
The policy holder is calling in to see why their son's (003) claim has denied what do you advise?
We would need to obtain verbal consent from the member prior to giving out any information. As well as offering the PHI form.
If a provider is needing access to their provider portal, what are your next steps?
Look up who their PR rep is and make sure they get with PR to get connected to their provider portal.
If you are running late to your lunch because you are stuck on a call, who should you contact?
Lead
An AS member calls in stating that their employer pays their premium, but that they received a invoice and doesn't understand why. What do you advise?
When it is a individual policy, the member will receive the invoices due to it being a individual policy.
A provider is stating that they need to know if the check has been cashed, what system are you using to check the information?
Zelis
If a member is needing a rx hold removed and states that they have paid the balance this morning, what are your next steps?
Verify that the correct balance has been paid
Verify that they have paid with a card
If a check is showing ACH reversal, what are your next steps?
Send a workflow to Finance to have a check reissued.
What is a willingness to help statment that can be used while on a call?
" I would be happy to assist you"
"I'm happy to help you with your concerns today."
"I'd be glad to look into that for you."
A member is calling in wanting to file a complaint due to the previous CSR Rep telling them to "Be quiet so they can explain", what steps are you taking?
Make your lead aware of the situation and advise you can send up a complaint workflow.
If you are needing to send a electronic ACH form, what system will you use?
Admin portal
A member is calling in wanting to void a payment that is showing the status as Settled, what do you advise?
We can not void settled payments.
Where do you check if a provider states that they submitted a appeal for a claim.
You would have to check in HSP to see if the appeal has been received.
What does L.E.A.P stand for?
L- Listen
E- Empathize
A- Apologize
P- Provide a path
Name 3 reasons you would open a workflow?
Claim clarification, accident injury form, OIC form, Complaints, ACH reversal check reissue.
If you are needing to get Lisa Burkes contact information, what system will you find it in?
Panviva
If a member is needing to terminate their policy and they are a TN member through the exchange, what do you advise?
They will have to get with Healthcare.gov/MP.
Once a refund letter has been issued to a provider, how long does a provider have to provide the refund before AHP recoups?
What does the letter state and how long does AHP take?
30 days is stated on the letter
60 days is how long they have before AHP recoups.
What kind of providers have access to the provider portal?
In network providers
List all 5 requirements needed in order to be reinstated when a policy has terminated due to non-payment
- No previous terminations
- No APTC is applied to the policy
- Requested reinstatement by the 15th of the following termination month.
- Pay full balance
- ACH must be set up