Account wellness
What should I view when performing an Account Wellness Check?
Possible areas to view:
You open the financials of a medication, and you see a $ amount in the ICL AND the gap line . What does this mean ?
This is a cusp claim.
This is when the medication is now entering the gap but also still in the initial coverage phase.
What is considered exceptional performance for Average ACW?
5 seconds and under
Describe what a PBM is?
Refers to a business that helps to manage the drug benefit of a medical plan through various cost-containment efforts for different groups (employers, managed care organizations, health plans, unions, etc.)
What is the name of the pet dinosaur on the TV cartoon "The Flintstones"?
Dino
What is the Account Wellness Check?
Assists with first call resolution to ensure we have discussed all opportunities and needs with our caller.
Can a member avoid the deductible ?
No, this is the first phase of the plan before the insurance begins to pay their portion . The member pays full cost of the medication until the deductible is met.
What is considered unacceptable performance for Average ACW?
50.01 seconds or more
What does MBR stand for?
Member
Whitney Houston went to the top of the music charts in 1992 with which Dolly Parton song?
"I Will Always Love You"
What should you always make sure is up to date when speaking with a member?
Verify phone and email address.
What is the gap or (donut hole)?
Member pays 25% of their plan's negotiated cost for prescriptions until the amount of $8,000 is met.
What is the adherence to sign in goal for exceptional performance?
95% or higher
What is a client?
Clients are health insurers, Medicare Part D drug plans, and Employers.
What 1997 movie features Will Smith and Tommy Lee Jones as undercover secret agents who police extraterrestrials?
"Men in Black"
What should you do if another prescription is available to fill?
Offer to fill the other prescriptions. Refer to Prescription (Rx) Refill/Renewal (Order Placement-004628)
What happens when the member reaches the catastrophic phase?
The member will begin to pay $0 for their cost share. For non-part-d drugs the cost is the same as the initial coverage.
What is unacceptable performance for adherence sign in?
Below 80%
What W.I. provides a list with phone numbers for Dedicated and designated clients?
Content ID : CMS-PRD1-105547
Transferring Calls to Dedicated and Designated Client Teams
In one of the most popular Dr. Seuss books, what won't Sam-I-Am eat?
Green eggs and ham
What is the verbiage for recapping and closing the call?
Designated Client Closing: Refer to the CIF for verbiage, if applicable.
Example: Today you called in regarding the rejected claim for Vyvanse through the local CVS pharmacy. We discussed the medication requires a prior authorization to be covered & I submitted an EPA form to the doctor’s office for that. I advised once the form is received from the doctor’s office it would take 24-72 hours to be completed. You have enough medication on hand until the decision is made on the prior authorization.
Example: Is there anything else that I can assist you with today?
How can you check a member's copay depending on the tier ?
You can click the plan summary tab or check start portal .
How can we improve member experience?
Call quality, FCR, Account wellness etc.
What is a DEP?
A person the member is responsible for. A dependent can be any of the following:
In a website browser address bar, what does “www” stand for?
World Wide Web