Call Flow
This is the act of repeating key details back to the member to confirm understanding.
What is recapping?
This metric tracks adherence to scheduled work times
What is SCAD?
This should be done before discussing account-specific details with a member.
What is verifying the member?
This resource should be used when you are unsure of a process or policy
What is E.Policies?
Remains Not Covered
What is Weight Loss Medications?
This shows understanding and concern for the member’s situation.
What is empathy?
The Metric for Scad
What is 94%?
True or false? You can proactively provide medication names to members.
What is false?
This should be pulled on every call for plan specifics
What is PSPP?
Sort doctors and facilities into tiers based on their performance and ability to save money.
What is a Multi tier plan?
The requirement to notify another party when speaking with someone outside of Aetna or when a call is transferred to a different individual.
What is call disclaimer?
Evaluates the quality of interactions based on predefined criteria, such as colleague professionalism, accuracy, and adherence to scripts or guidelines
What is ACE?
Can be provided to pharmacy staff to locate the member.
What is the alternate ID?
If unable to they can update credit cards on file.
Who is the Senior team?
Must be within 25 miles of the members home, a tier 1 (Maximum Savings), provider is accepting new patients, and correct provider role.
What is PCP Choice Criteria?
Should be offered on each call to allow the opportunity to reflect on members experience
What is the survey?
73.3% to meet
What is NPS?
True or False? You can opt a member's spouse out of Maintenance choice with out consent.
What is false?
You have done your due diligence and still need assistance.
What is contact the EMT line?
a benefit that provides each enrolled member up to 5 services from a pre-defined list of in network services covered at no-cost (100% paid) prior to the application of the deductible and/or coinsurance.
What is Flexible Five?
Medical, dental or pharmacy?
What are the suites of service?
You will save on this if you conference the member into the call.
What is hold time?
If you fail to validate the caller you can expect what?
What is a critical error?
This should be accessed on each and every pharmacy call.
What is the CIF?
Non-emergency charges incurred outside of the United States, Home births, Cancelled or missed appointment charges or charges to complete claim forms, Services for or related to the following types of treatment: aromatherapy; sensory or auditory integration therapy; primal therapy; rolfing; psychodrama; megavitamin therapy; bioenergetics therapy; vision perception training (vision therapy); or carbon dioxide therapy
What is Plan Exclusions?