Documentation
Member had a f/u with Dr Bell. Member asked the doctor about her BP bc it has been high. The doctor never answered her question. The member stated the doctor seem to be somewhere else mentally
What part of this is not related to the complaint.
This is an opinion, not related.
The member stated the doctor seem to be somewhere else mentally
KM1005774
Member experienced a delay in receiving medication(s) due to pharmacy's action, and the member ran out of medication(s)
QOC
Member called in on (11/27/2024) and is expressing dissatisfaction that she has a medical deductible of $200 that she must meet before plan will start assisting member.
Which Categorization is correct?
Complaint Reason: Plan
Complaint Sub Reason: Plan Benefit
or
Complaint Reason: Pharmacy
Complaint Sub Reason: Copay / Coinsurance - Deductible General Complaint
Complaint Reason: Plan
Complaint Sub Reason: Plan Benefit
How often does CMS Audits happen?
CMS Program Audits typically occur once every three (3) years if the previous audit is clean
Or
CMS Program Audits typically occur once every three (5) years if the previous audit is clean
CMS Program Audits typically occur once every three (3) years if the previous audit is clean
Member was denied service due to communication barriers with HC according to the member's daughter.
IS THIS A PASS OF FAIL BASED ON THE INFO IN FRONT OF YOU?
Who is the caller?
Member
Which timeline is it regarding?
UHC Dual Complete OK-S002 (HMO-POS DSNP)
What is the issue the call is regarding?
Verbal Grievance
Fail. Based off the notes they are not speaking with the member. Therefore this is incorrect.
When a compliant is about customer service such as
Rude behavior
Misinformation
Do we need to go into details of what happened?
No.
Apologized to the caller for their experience and assisted them with the reason for their call.
This is found in the ACD box under notes.
Member is calling in stating her doctor put her on Ozempic but the plan will not pay. What type of compliance is this?
CD
Member called in on (11/27/2024) and is expressing dissatisfaction alleges: the doctor is an (out of network provider) DR’s Name: Rachel Brown, Address: 500 Elm St Dallas Texas, Phone #555-55-5555 and is not accepting plan.
Which Categorization is correct?
Complaint reason: Provider/Facility
Complaint Sub-Reason: Provider not in network/refuses to see member/distance to provider
Or
Compliant reason: Provider /Facility
Compliant Sub-Reason: Unable to get an appt/refuse to see member
Complaint reason: Provider/Facility
Complaint Sub-Reason: Provider not in network/refuses to see member/distance to provider
What does CMS look for in their audits?
Correctly identified as a VG (or QOC)
Correct complaint categorization
Complete and accurate issue resolution
or
CAR (Corrective Action Required)
Observation – like an FYI
I-CAR (Immediate Corrective Action Required)
Correctly identified as a VG (or QOC)
Correct complaint categorization
Complete and accurate issue resolution
Member was denied services due to communication barriers with HC a compliant was filed that helper bee's wasn't able to understand the member.
IS THIS A PASS OF FAIL BASED ON THE INFO IN FRONT OF YOU?
Select the reason for the callers complaint
Customer Service
Select the sub-reason which mostly matches compliant
Customer Service
Who is the issue regarding?
Helper Bee's
FAIL. In the notes the agent said the issue is with HC but in the categorization she put Helper Bee's
When documenting can you copy and paste references related to the compliant from the JA?
No.
Any references to Knowledge Central can not be added to the compliant.
What not to document KM1005774
Pharmacy staff / pharmacist is rude, blunt, uncaring OR any behavioral complaint about the staff
QOS/VG
Member called in on (12/3/2024) is expressing dissatisfaction about plan; stating she has not received her 2025 member ID card.
Which Categorization is this?
Complaint reason: Enrollment/Disenrollment
Complaint Sub-Reason: ID Card Not Received
or
Complaint reason: Fulfillment
Complaint Sub-Reason: Fulfillment Not received after two or more request
Complaint reason: Fulfillment
Complaint Sub-Reason: Fulfillment Not received after two or more request
Once CMS request the audit from the plan, how long does the plan have to provide the requested information?
The plan is given roughly two weeks to provide universes to CMS.
or
The plan is given roughly 30 days to provide universes to CMS.
The plan is given roughly two weeks to provide universes to CMS.
Member was denied services due to communication barriers with HC.
IS THIS A PASS OF FAIL BASED ON THE INFO IN FRONT OF YOU?
Who is the caller?
Member
Which timeline is it regarding?
UHC Dual Complete OK-S002 (HMO-POS DSNP)
What is the issue the call is regarding?
Verbal Grievance
Fail. Based on the information provided is was said that services was denied. Which means we are dealing with an appeal or a verbal grievance. Not enough information to determine.
When documenting is it necessary to add expected appointment dates, date of arrival of medications, DME items etc as part of your documentation?
Yes.
Scheduled appt dates or when the member expecting to receive something, such as an order for meds or dme should be documented in full detail.
Grievance details should include KM1005774
Member called in stating she needs a new wheelchair. The chair that she has is 8 yrs old and is breaking down. What type of compliance is this?
MIOD
Member called in on (11/27/2024) and has expressed dissatisfaction with the plan and/or plan representatives. Member called in upset alleging that the call was disconnected while speaking with the previous agent. Member stated that the agent was working to get issue resolved when the call was disconnected.
Which Categorization is it?
Complaint Reason: Benefits
Complaint Sub-Reason: Complaint About a Call Center Rep/Advocate
Or
Complaint Reason: Customer Service
Complaint Sub-Reason: Customer Service
Complaint Reason: Customer Service
Complaint Sub-Reason: Customer Service
What is a Case Walkthrough consist of in an audit?
Complete and accurate issue resolution Including ensuring the member has not made additional contact to the plan about the same issue.
Documentation that clearly shows why the member is dissatisfied and what the plan did to assist them
Or
CMS test the plan’s universes for accuracy prior to selecting cases for a walkthrough to validate the universe accuracy within the applicable system (Maestro, CSP, EDS, etc.).
Complete and accurate issue resolution Including ensuring the member has not made additional contact to the plan about the same issue.
Documentation that clearly shows why the member is dissatisfied and what the plan did to assist them
BONUS 400
VGs (367602)
Documenting VGs (367606)
Defining CD Types (368386)
Organization Determinations (369520)
Take down these LS number and do them at your own pace if you feel you need the help. These are about 5 min long.
When documenting within compliance, is it important to add S# if you opened up another intent such as review benefits, search and assign?
Yes.
If additional resolution details can be found in another intent ( such as search and assign provider), is should include the S-case #
Grievance Resolution details should include KM1005774
Member called in upset bc he was scheduled for a 4-hour chair for dialysis treatment but receives less time due to being late. what kind of compliant is this
QOC
Member called in on (11/27/2024) upset because lab tests are not covered under annual physical exam. Advised the member the health plan takes these complaints very seriously.
Which Categorization is it?
Complaint Reason: Provider/Facility
Complaint Sub-Reason: Plan Benefits
or
Complaint Reason: Benefits
Complaint Sub Reason: Medical/Part B Drug
Complaint Reason: Benefits
Complaint Sub Reason: Medical/Part B Drug
What does "Findings" mean, when it comes to CMS?
Clean—no observed defects after research complete
Observation – like an FYI, CMS found an opportunity for improvement, but the member and plan reporting were not affected
or
CMS test the plan’s universes for accuracy prior to selecting cases for a walkthrough to validate the universe accuracy within the applicable system (Maestro, CSP, EDS, etc.).
Clean—no observed defects after research complete
Observation – like an FYI, CMS found an opportunity for improvement, but the member and plan reporting were not affected
BONUS 500
https://mr.video.uhc.com/media/t/1_3f8uazgc
APPEALS LINK. I WILL SHARE IN CHAT. THIS LS IS HELPFUL IF YOU NEED APPEALS GUIDANCE