Caller Scenarios #1
A member calls in looking for MetLife Dental, what do you do?
COLD transfer to MetDental and "wrong number" macro!
What is a Third Party Administrator; what do they do?
A company that organizes benefits for another company
What is one of the first things you want to do when you verify the patient's identity and OAP account?
Ask questions so you can select your macro
What do you provide to the member so the attorney can bill us rather than them?
Eligibility ID
A member calls because they're at the attorney's office now and need billing information. What macro do you use? Do you need notes?
Eligibility ID Request!
No notes necessary!
A member calls looking for a divorce attorney in his are; after locating his account, and verify coverage, you sent him a list of in network attorneys. What macro do you use? Do you need to add notes?
Referral Note Template.
If you wanted to add contested/uncontested you could, but it is not necessary.
True or False:
We can tell a potential member what their EXACT coverages would be BEFORE they enroll.
True!
We can send a fact sheet with general information on the plans as well
What FIVE steps should we take if we cannot find the member an attorney in their preferred area?
1. Zoom Out
2. Move the map
3. Look in closest major city
4. Offer fee reimbursement
5. CLIENT INQUIRY
Do we offer attorneys in every county in the continental US?
Unfortunately no.
A member calls in trying to create their online account. You assist in linking the MLP ID so they can see their coverages. What macro do you use? Do you need to add notes?
Website Issues!
No notes necessary
A member calls in looking for a felony attorney. Upon creating his OAP account, he's not a member. You've taken all your steps to verify his plan with no luck. What is your next step?
Explain situation to member, fill out Eligibility Inquiry. Inform member of window for call back
Where do you find additional verifiers for sponsors to ask during Eligibility Inquiries?
Eligibility Inquiry Tab on Sponsor Lookup Tab
True or false:
You do NOT have to read coverage scripts word for word, verbatim.
True!
You do NOT want to misspeak or misquote coverage
Can you send attorney lists to non-members? How do you do that?
Yes of course! Through the Attorney Lookup tab
A member calls in requesting an update on a payment we supposedly sent out to him for using an out of network attorney. What do you do?
Look up members info in the Fee Reimbursement tab. Apply Fee Reimbursement macro and provide status update.
You escalated a call with a difficult client to the Sup Queue. Afterwards the Sup calls to tell you to wrap up your ticket. What macro will you use? What will your notes say?
Client Intake!
The supervisor will tell you what your notes should say along with your part of the call.
True or False:
You can ask every member for their SSN to verify their plan.
FALSE!
Pay attention to the column that pops up during member search, it will tell you whether they're a membership# plan or SSN plan
What are our top THREE excluded matters?
Business
Employment
Appeals
Do we reimburse for out of network personal injury attorneys? Why?
Nope! PI attorneys are typically paid thru winning cases, since there is no set fee, we cannot offer a fee reimbursement.
A member calls in for an attorney for a speeding ticket in a county we don't have coverage in, how do you proceed?
Explain to the member that there aren't any local to that area, but we can go a bit further out. Zoom out, move the map, look at the next closest city. If still nothing, offer fee reimbursement. After call, file client inquiry
A member calls for a personal injury attorney from a car accident at work. The member was driving his own vehicle on the clock. Is this covered?
Unsure! Let them know that the attorney will be able to go into more detail about their matter.
If a member is unhappy with the coverage being offered by their sponsor, can they cancel their plan at any time? Where can you find this information?
No! You have to look at the enrollment period under the sponsor lookup tab
What is the difference between REOPENING and eligibility inquiry and FOLLOWING UP on an eligibility inquiry?
Reopen - original ticket less than 4 wks old
Follow Up - original ticket more than 4 wks old
True or False:
A client can go to an out of network attorney, then fire and rehire an in network attorney for the same matter.
False! Once you're out of network, you must stay out of network.
You're having trouble locating an MLP ID to verify coverages for a member. After you've tried all last name, zip, and sponsor combos, you see that you can look them up by their SSN, but the client refuses to provide. What do you do?
Explain that they don't have to provide any information they're not comfortable with, but it will be necessary to locate their account today. If they still refuse, tell them to reach out to their benefits department to work out eligibility details.