Types of Cases
Any positive comment about Humana or Humana At Home associate or program
What is a Compliment?
You must reach out to this team if Fraud, Waste and Abuse is suspected.
Who is YHA Customer Care?
A generic term used for any state agency that investigates abuse, neglect, and/or exploitation of a vulnerable adult; each state has a specific name for the state’s agency.
What is APS (Adult Protective Service)?
A statement of dissatisfaction from a member or member representative about Humana At Home, Human Inc., an associate, a vendor or provider, or other Humana-related entity which does not involve a legal risk nor rise to the level of an Occurrence.
What is a Complaint?
For questions relating to Humana Plan Benefits, I reach out to this team.
Who is Humana Customer Service?
When a member is not interested in visit, their CareBook and Five9 dispositions are changed to this status to the member does not receive another call from YHA.
This is not a permanent status and the member may receive a call in the future.
This type of case is negative feedback received from a member. Customer Care to follow up with appropriate teams to ensure the issue does not happen again. Since these members are not actually complaining, this may only be a notification to the affected teams and coaching may be needed for clinicians
What is an Issue?
The Call Center Representatives should contact them if a member indicates an emergency during a call such as suicidal thoughts, chest pain, a fall, etc.
Who is their Call Center Supervisor?
When this personal information is disclosed without the individual's authorization or permission.
The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.
What is PHI (Protected Health Information)?
A request for information about Humana programs without an expression of dissatisfaction.
What is an Inquiry?
ALL Humana Related Complaints. This is where we send issues relating to Humana plans.
Who is Member Services?
Number located on back of insurance card
A term used to identify allegations of fraud, waste, abuse, theft, exploitation, breaches of policy and ethics, and other acts of professional misconduct committed by clinicians, case managers and caregivers within Humana at Home and Home Solutions programs.
What is FWA (Fraud, Waste and Abuse)?
A complaint by a member (or his/her representative or provider) about the manner health care is provided by a Humana Medicare health plan, a Humana delegated entity, or by any other Humana-related organization. Grievances must be filed within 60 days of identifying issue.
What is a Grievance?
Immediately following an emergency, the Call Center Supervisor needs to send the Emergency Template to these teams.
Who is YHA Referrals and YHA Customer Care Teams?
When a member would like to take themselves off our calling list, their CareBook and Five9 dispositions are updated to this status so the member does not receive another call from YHA.
This is a permanent status and the member will not receive a call in the future.
What is DNC (Do Not Call)?