Authenticating
When authenticating accounts what SOP would i use?
Authenticate Accounts 80.07.04
If case is in clinical review and you did not build the case with caller can you reach out to an ump to finalize the case?
No advise case is still in review (you can provide TAT time), make sure no documentation is required. SOP: how do I handle a case status call? and How do I consult a pharmacist?
What are the 2 places we check to see who handles the case ?
Trigger & DCN SOP: How to identify who manages the coverage review?
What information must you use for documentation?
cold transferring is sending the caller over with you having no interaction with the other advocate-- warm transferring is the agent calling the next advocate and giving all needed info before transferring the caller to the line SOP: Transfer Call Handling
what is a warm transfer and what is a cold transfer ?
cold transferring is sending the caller over with you having no interaction with the other advocate-- warm transferring is the agent calling the next advocate and giving all needed info before transferring the caller to the line SOP: Transfer Call Handling
Provide the pieces of HIPPA/auth you collect for non-patient and patient level? and the title number for each
SOP: Authenticate accounts 80.07.04 --7 for non pt and 4 for members -- Patient first name
Patient last name
Name of requester and relationship to patient or title
Drug name
Plus 2 additional pieces of information (Zip code , Med strength Qty / Ds)
If they request peer to peer who do you call? and what is the procedure?
UMP and you get the mdo or prescriber on the phone then call the ump about the case the caller wants reviewed saying the mdo wants a p2p and then when the ump tells u connect the calls and stay on in the back ground until they are done and your calling the p2p line SOP : How do I handle a peer to peer request?
If the medication is not covered and no number in DCN, what is the next step?
look to benefits > benefits overview > then at the bottom under review and appeals under reviews under initial benefit see if its bcr ( it will have our name (esi) and number )if it is us transfer to bcr don't give the number out but, if its not us give the number to them to call and if no number there tell them to call the number on the back of the id SOP:How to identify who manages the coverage review?
What should the medium be when completing a fax? What should the medium be for completing a case by phone?
fax then phone -- SOP: commercial contact information and caller code quick refrence
Where do u go to find out how long you should wait when transferring a caller?
the hold chart that the SME's post several times a day
Do you have to authenticate a caller again if the phone is handed off to another person? and what must u tell the new speaker?
yes " this call is being monitored or recorded" -- SOP: Authenticate Accounts 80.07.04
You get a ccq that ask for specific documents and your wondering if the type of docs the mdo is saying they are sending are going to count / the mdo already send documentation and they want to know why that documentation was not enough-- who in the phone book are you going to call ?
the CRD rph line --SOP: How do i consult a pharmacist?
MDO calling to backdate a case and the case is locked. what are your next steps?
call rs --SOP: How to backdate a case
what are you going to document when u can not finish the ccq and have to fax the mdo and pend the case? You are working faxes
document that the fax could not finish the ccq and that u sent the ccq fax and SF ump review becuz when u send the ccq u are not unchecking the send to clinician review box so the case will go to the ump wb -- SOP: What are the best practices for case documentation?
where do you look to see if you can give the caller the transfer number?
SOP Phone list sulotion page or CRD Complete Phone list
If a case is pended and you need to complete it, what information do you need to verify before doing so?
verify the prescriber info SOP: COMMERCIAL CREATE AND COMPLETE A CASE 80.04.01
Do you cold or warm transfer to any UMP line?
don't transfer to crd UMP and warm transfer to PC UMP SOP: how do I consult a pharmacist ?
Lets say a caller called in about one medication and there member has 4 different accounts, the mdo does not have a preferred account they are calling about- what are u going to do to find out who handles the call and where to get the caller for a PA request ?
You need to look under all the accounts that u can and infor the caller of the options if a case is needed for one account or not and if the account is restricted you will infor the caller of the info for th eacounts that you can speak on then offer to transfer for the other accounts SOP:How to select the correct account for a patient in CSP?
when u complete a case over the phone when leaving a log what verbal decision notification option do you choses if any and what are the disposition and action code and medium
the physitican notification > live answer /xfre to CSR > manual outbound SOP: commercial contact information and caller code quick refrence
Centene call transfer carrier ID 2EAA provide SOP & Phone number
What are Centene Contact Numbers & 800-460-8988
scenario - a ESI PCA is trying to transfer a caller to you how do u authenticate
there's a script -Authenticate Accounts 80.07.04
You have a caller that qualifies and needs temporary coverage who are you reaching out to before you build the case?
CRD RPH com - How to enter temporary coverage ? and how do I consult a pharmacist ?
if the prescriber is the patient what is the procedure
you build the case but call ump to finish it like ask the ccq part and lock the case --SOP: How do i consult a pharmacist?
Where do we document if no cases on file and we don't handle the account ?
csp
What is the maximum hold time before we need to check on our caller again ? And if your caller hangs up or disconnects what is you next step
2 min and call back if urgent or document the lost call if no need to call the caller back -- SOP How do I handle a dropped call or chat? and Authenticate Accounts 80.07.04