Advocate for Member
What is a trigger?
This statement helps the member to know they have reached the right place and we will be able to resolve their issue
What is a Hero Statement?
In addition to reviewing a claim, we can do this step to give the member additional plan information
What is giving benefits?
NEXUS plan members will need this in order to be seen outside their PCP.
What is a referral?
Proactively calling your member's physician or pharmacy
What is provider outreach?
Scheduling a member to speak with our clinical nurse is an example of this type of referral
What is an internal program referral?
What is paraphrasing the member's need?
Advising our member of in network provider options although they are seeing an out of network provider is an example of this
What is in network provdier steerage?
You can provide this form via EZComm if member is traveling outside the US.
What is international claim form?
What is portal registration?
This site allows members to find additional support and resources in their community
Asking member if ok to hold, setting a time expectation, adhering to that expecation, and thanking the member for holding is an example of this
This option allows members to receive care for certain symptoms or illness without having to go to a doctor office, urgent care or hospital.
What are virtual care options?
We can offer this to expecting parents at no cost preventive in accordance with healthcare reform policy.
What is a breast pump?
This program is available to expecting persons with CBRE
What is Carrot Fertility?
9point6 and Hinge Health are examples of this type of referral
What is an external program referral
Doing this step allows the member to recall everything which was accomplished on the call and may help to drive any additional questions
What is recapping?
Our members can use these to help pay for medications and other health expenses
What are financial accounts?
A member can use this program to help find in network surgeons and plan an upcoming surgery to stay in network, streamline the PA process, and lower costs. It may be mandatory on some plans
What is Specialist Management Solutions?
Advising of alternatives such as lower cost medications or more cost effective facilities i.e. urgent care vs ER
What is advising of lower cost alternatives?
Listening for these helps the advocate to better understand the member's need and offer appropriate programs and resources.
What are trigger words?
Giving your number and advising of our voicemail and callback timeframes are part of this step in the call
What is giving your direct extension?
These medications are often prescribed for A1C and Diabetes but can also be ordered for weightloss. These medications often cannot be covered if a comorbitity is not present
What are GLP-1s or weight loss drugs (Ozempic, Mounjaro, semaglutide, Zepbound, Sexenda, etc.)
A new parent will need information on this to ensure the baby is enrolled in the plan.
What is the newborn process?
An expecting parent will need a list of these after delivery
What are in network pediatricians?