Appeal vs Grievance
The member is upset that the prior authorization for an injection was denied.
This is an appeal.
Reject grievance as misclassified and depending on if mbr was advised of appeal process, send the misclassified letter.
The member is dissatisfied with their copay for NEXIUM CAP 40MG.
CVS. Plan Benefit Part D.
The member is upset that no one advised him that you needed to have prescription drug coverage once you turned 65.
Part D
*Grievances against LEP should be classified as Part D
The member is not happy about having to pay an LEP. I have explained that they may submit an LEP reconsideration to Maximus.
This is a LEP appeal.
The grievance should be rejected-invalid and no SF ticket created since they were provided reconsideration education.
The member asked if transportation is part of her plan. I explained that routine transportation is not part of their benefit and provided community resources
Invalid. This is an inquiry.
The member is upset that she is being charged a $5 copay for a specialist visit. The CSR confirmed this is the member's benefit for that service. The member is upset and stated that the previous CSR she spoke with advised her that she has a $0 copay to see a specialist.
This is an appeal and a grievance.
The member upset with the $5 charge is an appeal. The member upset with the previous CSR is a grievance.
*Because the CSR didn't advise of appeal rights on the call, we should include this information after we address the grievance.
The member states that their enrolling agent did not inform them of their Part D premium.
Clover. Part D Marketing.
The member is upset with the CVS Over the Counter location access within your area.
Part C
*OTC is a supplemental medical benefit. Grievances about OTC should be classified as Part C.
The member is upset that they received an LEP attestation letter again. They are tired of having to complete this annually.
This is a valid grievance and should be responded to via letter.
*This would be categorized as CMS issues. This is a CMS requirement that Clover sends this letter.
Mbr called and was disenrolled 12/31/19. Mbr is upset with the member identification card he received. Mbr is set to be re-enrolled with Clover on 2/01/20.
Valid grievance.
*Termed members have 60 days to call and complain.
The member is dissatisfied that they received a bill from Carepoint Hospital (INN) provider for the amount of $25,000 for DOS 01/01/20. CSR reviewed the claim and determined the entire allowed amount denied for HAU- medical records not received.
This is a balance billing issue that needs resolved through the grievance process.
**INN providers are not allowed to balance bill members when the denial is provider liability.
The pharmacy would not allow the member to pick up their Lisinopril because their plan in inactive.
Clover. Enrollment/Disenrollment Part D.
The member was upset with Dr. Julio due to the prescription for insulin not being refilled in a timely manner.
Part C.
*This is a grievance against the provider even though it is about medications, this would be classified as Part C.
The member is dissatisfied with being unable to pay the Late Enrollment Penalty (LEP) over the phone.
This is a valid grievance against Clover payment options.
Mbr called on 01/10/20 and is upset that he received a Quarterly EOB for Q4 2019. Mbr was disenrolled from the plan on 10/31/19.
Valid grievance. Even though mbr was termed 10/31/19. We reviewed and confirmed we sent Q4 EOB on 01/01/20.
*Remember it is 60 days from the incident date. Since we recently sent this correspondence to the mbr, this triggered the mbr to call and complain.
The member's representative is upset the mbr is being discharged from the Skilled Nursing Facility. The rep doesn't feel the mbr is ready to be home alone.
This is an appeal.
**Technically a Livanta appeal
Reject grievance as misclassified and create urgent SF ticket to ensure call is made to give correct process.
The member states that she picked up her ZIPRASIDONE CAP 60MG prescription at CVS pharmacy today and the staff was very rude.
CVS. Customer Service Part D
The member's AOR expressed dissatisfaction Mg217 Medicated Coal Tar is not part of the OTC catalog.
Part C
*OTC medications not on the catalog would be classified as Part C since this is a Part C benefit.
The member's AOR is upset the member received a bill for the late enrollment penalty fee (LEP).
This is an LEP Appeal.
Reject grievance-invalid. SF ticket would be created for Tier 3 to contact AOR back to give LEP Reconsideration information.
Member called upset that she was disenrolled for loss of Medicare Part B. The member is extremely upset that Clover would disenroll her when she knows she has Part B coverage.
Valid grievance. Even though issue is related to Medicare Part B, the member's perception is that it is Clover's error and fault.
The member is extremely angry that their authorization was partially approved. The member said that they will sue Clover if anything happens to them. The CSR advised the mbr they can appeal the decision and the steps are listed on the denial notice. The member is upset and said that he never received this notice.
This is both an appeal and a grievance.
**Nothing needs to be done with the appeal portion bc the member was given the process on the phone.
The member has been out of insulin for a week because their doctor took so long to send the prescription to the their pharmacy. The pharmacy finally called her to pick it up but it cost more than what they paid for it before and cannot afford it.
This is a split grievance.
Clover will address the Part D QOC
CVS will address the Plan Benefit Part D
The caller is dissatisfied that they were not advised when they were enrolled by the agent that they would have a deductible for the 2020 plan year.
Part D.
*This would be categorized as a Part D Marketing grievance.
The member is dissatisfied with the Late Enrollment Penalty (LEP) bill you received. The CSR explained what the LEP is and how to submit a reconsideration. The member screamed that he was never informed and disconnected the call.
This is both an LEP reconsideration and a grievance.
*The LEP reconsideration was addressed during the call and nothing needs to be done regarding this.
Member calls and validates account. Member's spouse is also on the call and member gives verbal permission to also speak with the spouse. During the call, the member spouse indicates that they were upset they were given wrong information when enrolling into the plan with the agent. The CSR advised that a grievance will be filed. The member chimes in and says yes you better.
Valid Grievance.
*No AOR chase is needed since member and spouse were both on the call and the member validated the grievance being filed.