Complaint Process
Can you check the escalation box on a normal case and PA case?
Yes
Fill in the blank.
Give honest _________ and always speak of SmithRx in a _________, professional manner. Do not say anything that could lead the reviewer to believe SmithRx “______”.
Answers, positive, Has issues
In the example below does the name qualify to be considered first and last name for Smithrx Verification?
Name in C3 is Jane Doe-Smith
Caller provides Jane Doe
No , if account has "Jane Doe-Smith" , the call will not pass verification if the member verifies as Jane Doe or Jane Smith
Article used to collect information about a provider and send them a PA when its needed?
Prior Authorization (PA) Workflow.
This TL Collects Ducks
Aubrie
Provide one example of a complaint you would create a complaint case for?
Bonus 100 points per person that has an example. TL will go around the room.
What do you do if you don't understand or are unsure?
Ask clarification questions , if they dd not ask you by name you can let another person answer, to say you aren't sure but will get back.
If a caller/account member is calling for someone other then themselves what article should we use at this point? (age of member doesnt matter)
MSS Approved Advocate (AA)
Article to provider steps for members to check formulary, find my meds, and get a electronic ID card?
Member Self service
In January 2026 there is a PTO ______.
Freeze
What is required in the notes of a complaint child case?
Reason for complaint.
How it was resolved or what will be needed to resolve.
Answer questions as simply as you can. If the review asks a Yes or no question, answer with a?
Yes or No
In the example below does the name qualify to be considered first and last name for Smithrx Verification?
Name in C3 is Jane Doe Smith
Caller provides Jane Smith
Yes , If "Jane Doe Smith" calls, the member needs to provide Jane Smith to pass verification. The member could also provide Jane Doe Smith.
Not covered (NC) Workflow
This TL collects Hour glasses
Ronni
Fill in the blanks.
Case reason will ________be ___________
and is ________ for _________cases.
Always
Complaint
Required
Complaint
Who can you report a compliance concern to?
Answered correct : Yes
TL has a bonus question worth 100 points.
Supervisor, Manager, HR , Legal, Leadership, Compliance team, Anonymous (handbook link or QR code)
Bonus Question:
Name 1 Location the QR code is located in SmithRX.
In the example below does the name qualify to be considered first and last name for Smithrx Verification?
Name in C3 is Jonathan Doe
Caller provides Jon Doe
No, If the member's account in Salesforce/Portal says "Johnathan Doe" and the member provides "John Doe" or “Johnny Doe,” that WOULD NOT pass verification.
Article used for Reject 79?
Laker Reject Code Workflows
or
Override Request Workflows
Who is our ops manager
Amber
Why is the complaint process important?
URAC
What are we protecting when we lock computers, verify ID , lock drawers with papers in them, avoid public discussions about members, send secure emails, shred papers with member info, and leave printer free of paper?
We are protecting PHI.
How many pieces of verification for member are required for a benefits investigation?
&
What article do we use for Benefit investigations. (MSS)
3 pieces
MSS Benefits Investigation.
Article used for member coverage?
Drug Coverage
We should be using C3 for which scenarios?