Network
On a call Agent says provider is INN. What do we do next?
PB:"Just to confirm, the Practice is INN with the patient's plan, correct?"
Patient found in system but the agent does NOT have access to the plan or cannot locate correct department. How do we process task?
Select: Agent unable to locate active member plan
Agent does not give a coordination type listed in drop-down. What do you do next?
PB: "How do you coordinate benefits, by Non-Duplication of benefits, or Come Out Whole, or Standard COB?"
For a private Fee For Service Plan how do we enter it?
Headset Plan Type
and
Select Policy Type: Medicare Advantage
For PA the agent says I can not answer if it is required what do we do?
We will escalate at the end of the call.
On a call practice is out of network. What is the next step?
PB:"Does the patient have OON benefits?"
"How to be considered in network"
Out of Network
(collecting both in and out of network)
See Additional Information/Links and Comments; if patient has no OON benefits.
Agent refuses to speak with Digital Assistant. How do we process task?
Select: Agent refused to speak to AI voice
If the agent can not answer if the primary insurance denies, will this plan consider covering as primary? What do we do?
Headset
If the agent says this is a "Comprehensive Medical/ TRADITIONAL" Plan, how do we enter it?
Plan Type: Indemnity
Policy Type: Commercial
If PA on file is expired for a different provider,how would we enter it?
Not on file.
On a call the Agent asks " Are you in participation with your local?" What do you do next?
PB:"Can you check that please?""I don't have that information"and then"Does the patient have Out of network benefits?"
If yes, Unknown
(Collecting IN & OUT)
Ask how to be considered in network.
If No, unknown(collecting In).
Ask how to be considered in-network
Task Note "This plan has no out of network benefits".
Agent states that the plan is handled by a different department and we are unable to complete benefit verification. How do we process the task?
Select: Need to call different phone number
Does this plan cover 100 percent of the 20 percent remaining from Medicare? When do we ask this question?
Non Standard Supplement Plans
If the deductible is included in the OOP, but the deductible met amount is larger than the OOP met amount. What do we do?
"Can you explain why the deductible accumulation is greater than the out of pocket accumulation?" (If the deductible met is greater than the out of pocket met)
If the agent says "Prior authorization turnaround time is going to be 180 days" what do we do?
PB:“Can you check that, please? I usually get a different answer in similar cases.”
On a call Agent states " Patient has no OON benefits." What do we do next?
PB: "How to be considered in network?"
Collect INN if Agent is willing to give INN
If Agent is not willing to give INN, collect OON Add TN:Provider is out of network, representative unable to provide in network benefits.
How do we process a task if we forgot a PB or prompt?
Select: Operator Error (reason)
For a dual complete plan, if the state administers the medicaid what percentage should we expect in cost share?
If payer administered it should be covered at 100% if it is state administered cost share should show 20% coinsurance.
What do you do if the deductible max is higher than the OOP max?
Can you explain why the deductible maximum is greater than the out of pocket maximum? (If the deductible Max is greater than the out of pocket Max)
What do we do if the agent says the Jcode has a "18%" or "19%" or 28% or 29%?
Can you check that, please? That coinsurance amount normally applies to Durable Medical Equipment.
On a call Agent states that " Practice NPI matches but address is different". What is the next step?
"I still have some plan questions, but when we get to the benefits, can I have both in and out of network benefits?"
AND
"What is the in network address?"
In Network with Different Address
(Collecting both IN and OUT)
How many attempts must you make for unreachable before we can fail?
2
If the agent can not answer "How this plan coordinates" what do you do?
You PB and then escalate at the end of the call to a Supervisor if they still can not answer
If an agent says: “For tier 2 drugs it will be a $40 copay, and for tier 3 drugs it will be a $75 copay.” What do we do next?
Which tier applies to this benefit? If unknown collect all tiers. Also add TN: Plan has multiple tiers. $X/$X/$X for the product, $X/$X/$X for the administration, $X/$X/$X for the specialist office visit.
What is the correct prompt we ask instead of deductible question if its a medicaid plan?
"Is there a monthly spend down for this plan and how much has been met?"