Call Flow/Authentication
A member has verified they are calling in for their Spouse and given their name and the call is IVR authenticated, what question do you need to ask next?
Is the member aware you are calling today?
If the member is requesting to backdate a PA, how should you proceed?
contact the Precertification Department for assistance. If they are unable to backdate the PA, refer to Aetna - Initial Benefit Review (IBR) Process for non-PA Benefit Rejections.
Where do we navigate to in compass to find an order a member is needing the status for?
Navigate to the Claims Landing Page, then click the Mail Order History tab.
Fill in the blank; ________ does not apply to medications taken on a short-term basis such as antibiotics and Specialty Medications.
Maintenance Choice
What is our NPS goal and stretch goal?
NPS goal: 49% Stretch goal: 60%
A call comes in and it is a transfer from member services, what is the first thing you should ask the representative?
Member is calling to check the status of her Prior Authorization for Ozempic 0.25mg, you see that an EPA was sent to the Prescriber already and it still shows as "In progress", how should you proceed?
--- I see that a Prior Authorization has been started for this medication. Either the provider has not yet responded, or it has been less than 1 business day since they responded, and our system has not yet been updated. Please follow up with the provider for the status of this Prior Authorization. If you’d like, I’ll be happy to reach out to them now on your behalf.
How do we see the details of an order within compass?
Click the chevron next to the member’s name to expand the Rx details of the order.
What benefit was recently added this year to give members more options where they can choose to fill maintenance medications? What plans are excluded?
Effective April 1, 2024, we will further expand the Maintenance Choice® (MChoice) program nationally to include Kroger affiliated pharmacies. This expansion excludes Federal plans
What is our OSAT goal?
OSAT Goal: 78%
After you have authenticated the member and verified they are calling for themselves, what question do you ask them next?
What can I help you with today?
For Prior Authorizations related to age or gender, what should you do?
Do NOT read the messaging to the member. Instead, only indicate that authorization must be obtained prior to the medication being prescribed to the member.
How do you locate the prescriptions within an order in compass?
click the chevron arrow next to the Order Number link to expand/collapse a preview of the prescriptions in the order.
Fill In The Blank; The state mandates that restrict programs like Mchoice are only applicable to ___________
fully-insured plans.
What Scores count as a promoter?
9 or 10
What are the steps to closing a call properly?
1. Recap the call. 2. Resolution Question 3. Closing Statement: "Thank you for calling. It's been a pleasure speaking with you, have a great day!"
What is the Turn around time for Prior authorizations?
The Precertification Department will fax a form to the prescriber within 24-48 hours. Once the completed form is received from the prescriber, the Precertification Department will process the request within 24-72 hours. The Precertification Department will review the information and send a letter to the member and the prescriber with the decision.
What all is listed on the Order Details Screen in Compass?
Order Number, Order Status, Order Received Date, dispensing Pharmacy, receive mode, Consolidated, and Rx Actions and Order Actions Dropdown.
Member is requesting Opt out effective dates to be back dated for a paper claim, how do you proceed?
arm transfer the caller to SRT. The Senior Resolution Team will verify CIF to check for Client specific allowance.
Name the Helping with heart Actions.
I provide a friendly greeting and offer my help. I ensure the safety and well-being of others. I listen and make sure I understand before I act. I remove obstacles to make experiences easier. I follow through, working with others to find solutions. I create heartfelt, personalized moments.
If a call is NON IVR Authenticated, what 4 authenticators must member give you before moving forward with the call?
Full name, DOB, Member ID (if unable to give ID you can ask for rx name, rx number.) and Zip code. ( if don't have zip code then caller can give plan sponsor name.
Which three places can you initiate an EPA in compass?
The Claim Details or Transmission Details screen, The Claims table (only if a valid PA rejection is on the claim), and A test claim (only if a valid PA rejection on a test claim).
What is the Turn around time for a refill order with no issues?
You can expect your order to ship from our pharmacy in 1-2 business days. Day 1 is the day the order is placed. Orders ship on the first business day available upon processing being completed. As a reminder, this does not include actual shipping time after it leaves our facility to when you will receive your prescription.
Member is at the pharmacy to obtain a 30day supply of Omeprazole 30mg, their pharmacist told them that their refills are not covered by their insurance so they call in frustrated and confused. You identify it is a Mchoice Reject and they have the Mandatory Mail order benefits. They state they have no idea what you are talking about and have had no prior knowledge of this being apart of their plan, how do you proceed?
Follow Educational Override Process of WI Verify that one of the following situations applies for any member with MMOD or MChoice (regardless of what the CIF says): Member has not been advised or Member does not understand their Maintenance Choice benefit design. Advise the member that this is a 1x override and educate them on their plan guidelines and the benefits of Maintenance Choice and Mail Service.
How do you receive credit for viewing survey details in Medallia?
Click on the view details option within survey responses