Grievance Systems
This system houses all of our grievance and appeals cases received, and where notes and letters are written.
What is iCare Path?
This department is the one that initiates and sends over majority of our grievances.
What is Customer Service?
This is the best place to verify who customer service was talking to when a grievance was filed.
What is the top of the grievance ticket?
This is the site used when we need to send something for transportation, dental, hearing, vision, Quest/Labcorp cases.
What is the NAS sharepoint site?
This is the system we use to research plan benefits and costs.
What is Sensentia?
What is Care Central (UM/PEGA)?
This department works with us to ensure that member's are treated well at appointments and not billed incorrectly.
What is Provider Relations?
If a third party filed a grievance on behalf of the member, this is the only way that the grievance would be valid without an AOR/POA/EOE or phone call to the member.
What is if the grievance indicates that the member was present for call and approves the grievance details at the bottom of the ticket?
When a member needs to receive materials in an alternate format, this is where the request is sent.
This plan material is mailed to all members prior to the Annual Enrollment Period, to allow the ability to review the next year's benefits and switch plans, if desired.
In order to see coinsurance or deductible information on a claim, rather than looking in claim inquiry, you'll want to lean on this system for claims views instead.
What is Xcelys/Xcelys CMR?
What is Appeals?
This is the only authorization document that is valid if a member is no longer living.
What is an Executor of Estate (EOE)?
This is how we submit an appeal if needed.
What is an Xcelys CMR ticket?
This benefit is provided under some plans, but member's are required to meet specific qualifications to receive them.
What is SSBCI benefits?
This system is best utilized for locating pharmacy Explanation of Benefits, and member's Part D accumulations for current benefit stage status.
What is ESI Evernorth?
We work with this department to ensure that member's are able to successfully fill all medications and pay the appropriate cost for their medications.
What is Pharmacy?
These two actions are required if we call the member on a 3rd party case and they take ownership of the grievance.
What is updating the case received date to the date of the call, and changing the complainant type to member?
When there are no specialists in network with 75 miles of a member's home, this site will review and provide an out of network authorization if needed.
What is the UM routing tool via sharepoint?
This benefit is available to all members, and does not show in sensentia.
What is Healthy Rewards?
If a member needs a coverage determination, you'll want to check this system's "care" tab before sending to the pharmacy issues sharepoint route.
What is Compass?
This department is vital in ensuring member's are able to access benefits and providers that they are in need of receiving/seeing for the betterment of their health, regardless of if the benefit or provider is covered.
What is Utilization Management (UM/authorizations)?
This is the amount of time that an AOR form is valid.
What is a one year from the date the member signed the document?
In order to review a member's pharmacy costs by drug tier and stage, you'll need to flip sensentia to this view and include the member's LIS information.
What is the Part D Matrix?