Hip HIPAA Hooray
Why do we verify HIPAA on every call?
To protect PHI and comply with federal privacy law (HIPAA).
This is what MMR grievance stands for
What is a Marketing Misrepresentation (MMR) Grievance
When are monthly Food & Home Card funds loaded?
On the 1st of each month.
What’s one reason to refer a member to a Community Guide?
Examples: Medicaid/MSP renewal, food insecurity, housing resources, financial hardship, prescription cost help.
We can say a member’s full name before HIPAA is verified.
False.
If CVS tells you they already verified HIPAA, can you skip re-verifying with the member?
No – external transfers must always be re-verified with the member.
Do members need to be upset in order for us to file an MMR grievance?
No – CMS requires MMR grievances even if the member is calm.
Can unused Food & Home Card funds roll over to the next month?
No – funds expire at the end of the month.
Can Community Guides take inbound calls directly?
No – they don’t have an inbound function; use Slack/case process.
A family member can repeat identifiers for a member during HIPAA verification.
False – the member must provide all identifiers themselves.
A caller joins mid-call while the member is on the line. What must you do before sharing PHI with them?
Get their full name, relationship to the member, and member’s permission (verbal or on file).
Can an MMR grievance be filed for a prospective (not yet active) member?
Yes – MMR grievances apply to prospective members too.
A member asks you to replace their Food & Home Card. What should you do?
Transfer to CVS OTC – they handle replacements.
(scenario): A member calls back while a Community Guide engagement is still open. What should you do?
Do not create a new case — post in #community-guide-team with notes and document in the call notes.
If HIPAA has been verified earlier in the call, but a new person joins, we don’t need to do anything.
False – must document their info + member’s permission.
A member’s address is “123 Main Street.” If the caller says “123 Main,” is this a valid HIPAA identifier?
Yes – missing suffix is ok if everything else matches.
If a member cancels their enrollment, do we still need to file an MMR grievance?
Yes – canceling does not remove the need to log the grievance.
Can PHIs activate or attest for a member’s Food & Home Card?
No – only the member can.
(scenario): A member had a closed engagement about Medicaid renewal. They call back about the same issue. What should you do?
Do not create a new engagement
Pharmacy Guide transfers can be attempted unlimited times until one answers.
False – only attempt 2 warm transfers. After that, create case
(scenario): A profile lists the member as female, but the caller sounds like a male. The caller passes HIPAA verification. What should you do?
Proceed as normal — do not question a member’s gender or identity if they verify HIPAA successfully.
If a member says they don’t want to file an MMR grievance, should we still log it?
Yes – CMS requires we file it for compliance and tracking.
(scenario): A member’s plan started in January. In February, they call asking to roll over their unused January Food & Home Card balance. What should you do?
Nothing — the first month of enrollment (January) automatically rolls into the second month (February). No manual rollover is needed.
(scenario): A member calls in, and you see there’s already an active Community Guide engagement. What’s the correct next step?
Do not create a duplicate case — post in Slack and document in call notes.
(scenario): You attempt two warm transfers to the Pharmacy Guide team, but no one picks up. The member still needs help with their medication. What should you do next?
Create a case under Medication Adherence, assign to Pharmacy Guide or MAGII Inbound user group (if automation outreach), document all details in the notes, and do not close the case.