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 Doc Requirements
Member experienced a delay in receiving medication(s) due to pharmacy's action, and the member ran out of medication(s)
QOC
When categorizing a compliant should we say to the member that we will file a grievance or advise one is being filed?
DO NOT offer to document a grievance or advise one is being documented.
This is found in the ACD box in red within the compliance steps.
Ohh wow, you finally answered. It took you like 30 min just to answer my call
Member is expressing dissatisfaction due to long hold time.
member is requesting extended transportation
OD
When a compliant is about customer service such as
Rude behavior
Misinformation
Issues left unresolved, not being assisted
Language assistance
Difficulty understanding advocate
With any call center, HouseCalls, provider office staff, hospital staff, facility staff, pharmacist and pharmacy staff, and OptumRx.
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.
CD
When categorizing a broker compliant is it necessary to fill out the broker compliant form?
Yes. compliant isn't complete without form being completed
Hi. I've been waiting 2 hours for my ride home, where is my ride?
Member expressing dissatisfaction to long wait on ride/ late pick up.
VG
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.
Pharmacy staff / pharmacist is rude, blunt, uncaring OR any behavioral complaint about the staff
QOS
Member states that she was finished with her doctors appt at 3pm. She activated her will call to return home at 3.05pm with an expected pick up at 3.15pm to take her home but driver never showed up.
Is it important to categorize if the trip was place using Medicaid or Medicare?
Yes. For DSNP plans: We need to know if the ride was booked using the member’s Medicare or Medicaid benefit
Can you put me on hold without the music? I really hate that hold music!!
Complaint about Hold Music
Member is inquiring why fulfillment is late
not a grievance; just an inquiry
When documenting is it necessary to add expected appointment dates, date of arrival of medications, DME items etc as part of your documentation?
SCHEDULED APPT DATES OR WHEN THE MEMBER EXPECTED TO RECEIVE SOMETHING, SUCH AS AN ORDER FOR MEDS OR DME, OR FULLFILLMENT MATERIALS.
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?
OD
OTC products not received
OTC/ Products and supplies
I'm very upset, I was transferred several times
Complaint about Call Time/Hold/Transfers
Member needs her NovoLog covered
CD
When documenting within compliance, is it important to add S# if you opened up another intent such as review benefits, search and assign?
IF ADDITIONAL RESOLUTION DETAILS CAN BE FOUND IN ANTOHER INTENT (SUCH AS SEARCH AND ASSIGN PROVIDER), INCLUDED THE S-CASE NUMBER FOR THAT INTENT
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
Outbound Campaign/ promotional Calls
Plan/Excessive Calls from plan or plan vendor
Member called in expressing dissatisfaction alleging that they cannot access the Optum Rx website.
Complaint about OptumRx website
Member loves her Navigator
Happy- not a grievance