Care Gap Definitions
Also known as an AWV, this health screening is once a year with the members PCP. It gives our members the opportunity to talk with their doctor about taking control of their health and staying on track with important screenings and vaccinations.
Annual Wellness Visit (AWV)
The member already completed the screening.
Already Had Service
What action code should be used if member was unable to verify HIPAA?
Unable to Verify
What call driver would we utilize to document our PSO notes?
Other Call Driver
Section 5: Voicemail
This health screening is commonly given during the fall/winter months to protect from a common and contagious respiratory illness. This screening can be completed at the PCP office or any clinic that has this vaccine available.
Flu Shot Vaccine (FVO)
The member states that they don't believe this particular screening applies to them.
Member Denies Care Gap.
What action code should be used if member is currently residing in a nursing facility?
Member Resides in LTC/SNF
What action item would we use for voicemail calls?
What are the three different pathways for verifying appointments?
1. Verifying appointment and no additional care gaps need to be scheduled (Path A)
2. Verifying appointment and need to schedule appointment for different care gaps (Path B)
3. If scheduling new appointment (Path C)
This health screening is only to be mentioned to female membership. This screening can be completed by visiting a radiology or diagnostic center. The procedure associated with this screening is referred to as a mammogram.
Breast Cancer Screening (BCS)
The member will be going to a provider who doesn't schedule appointment times.
Walk-in Appointment
What action code should be used if member speaks a different language and refused to speak with translation services?
Language Barrier - Declined Translation Services
What is the 2nd level reason code for successfully scheduled appointments?
Appointment Scheduled
What should we utilize in the script if we are struggling with a member who is pushing back on scheduling the screenings? (Located in Section 23)
Rebuttal Talking Points
This screening can be completed at an ophthalmologist office. The doctor will examine the retina of the eyes for any changes that could lead to vision loss or glaucoma. This screening is once a year.
Diabetic Eye Exam (DRE)
The member stated they are completing the screening virtually.
Telehealth Appointment
What action code should be used if member provided us with a new piece of contact information (ex. phone number)?
Member Updated Contact Info
What is the top level reason code for every PSO call documentation?
HEDIS Care Gap
What can we utilize if the member asks us to further explain what an Osteoporosis Management screening is?
Educational Talking Points
This screening is where the PCP reviews the members ability to perform daily tasks. This ensures that our members are receiving the care they need to fit the challenges they face on a daily basis.
Care of Older Adult Functional Status (COA-F)
The provider refused to schedule the appointment.
Provider Pushback
What action code should be used if agent feels the member was annoyed or dissatisfied with us calling?
Member Temp - Member Dissatisfied
What are three items that need to be included in an appointment scheduled documentation ticket?
1. What care gaps were addressed
2. Date and Time of the appointment
3. Disposition that was used (Call Complete)
4. Site Code
5. Providers office information (phone number, rep you spoke with)
What are the five different Health Barriers our script covers for those members with certain needs?
Clinical Complexity, Health Literacy, Health System Engagement, Mixed Factors, and Physician Relationship