Call Flow
Per WI Content ID : CMS-PRD1-095822Universal Medicare D - Consultative Call Flow (CCF) Process
how should you close the call?
A. Have A Great Day, It's been a please speaking with you.
B. Thank you for calling. It’s been a pleasure speaking with you, have a great day!
C. If there is nothing else have a great day!
B. Thank you for calling. It’s been a pleasure speaking with you, have a great day!
A member calls in with Client code X20AA, and stated they lost their ID card and needed a new one after viewing the CIF, what would be your next steps?
KelseyCare Advantage handles, warm transfer member
Per WI What are some tip on how to avoid Non- interaction/silent or mute time?
Content ID : TSRC-PROD-066076
Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfer
Tips to avoid Non-Interaction (NI) time:
Walk the caller through what you are doing and keep the member engaged.
Use positive words and phrases, such as: “I definitely want to give you an accurate answer, I’m going to research this.”
Avoid muting the call/headset. Mute should only be used temporarily to prevent members from hearing sneezing/coughing, etcetera.
Information that “May” or “May Not” be shared with Third Party Callers…
Low Income Subsidy we can provide a Yes or No answer if the member is cover.
"May" or "May not"
“May”
True or False Third party callers can change account phone numbers, add or remove current payment methods and request a override
What WI will you will find this information?
False
No changes to the account can be made by the caller.
Examples of account-level changes include the changing vital details on an account:
Please refer to:
Content ID : CMS-2-028920
HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS
1.What authenticators are needed for a Non-CTI/IVR Authenticated or Partially Authenticated person Calling for Self and or Power of Attorney?
2.What WI will you find this information?
Hint: Call Flow
Caller must provide full name of member, if only first name is given prompt the caller for the last name
CCR must ask the member "Are you calling for yourself today?"
what is the date of birth please?
can you confirm the Member ID?
To validate the account, what is the Zip Code?
2.
Content ID : CMS-PRD1-095822
Universal Medicare D - Consultative Call Flow (CCF) Process
Who handles Grievance and coverage determinations for client code X8626?
Where did you find this information?
The client.
CIF: Content ID : CMS-PRD1-114275
Indiana University Health Plans Medicare D
When returning to a caller, after placing them on a hold what should you do/say?
HINT: Step 12
What WI will you find this information?
Hint: Warm
Thank the caller for holding, apologize for the delay and introduce the caller to the receiving party. Wait for the receiving party to take over the call before disconnecting.
Clinical: The Clinical Care Technician/Pharmacist will take over the call without needing the CCR to remain on the line.
If the Clinical Care Technician/Pharmacist requests you to remain on the line, inform the caller that you will remain on the line.
If not brought into the conversation within two (2) minutes, ask if your assistance is still required. This should only occur during a pause in conversation, so no interruption occurs. If advised assistance is no longer required, you may drop from the call.
Once your assistance is no longer needed on the call, inform both parties that you will be dropping off the call.
Click Leave Conference to disconnect yourself from the call.
Icon - Important Information Do NOT Click End Call as this will disconnect ALL parties.
Icon - Important Information Staying on the line silently can lead to a HIPAA violation and breach of member privacy. If remaining on the line after completing the warm conference/transfer, notify the Clinical Care Technician or Pharmacist and the caller.Content ID : TSRC-PROD-066076
Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfe
What is Non-Member or Third-Party Caller Types?
Calling on behalf of an Adult Member (18 Years of Age or Older)
Calling on Behalf of a Minor Member (Under the Age of 18 Years Old)
Retail or Other Pharmacies or Third-Party Insurance PBM Vendors
Providers
Hospital or Emergency Medical Personnel
Client and Plan Representatives
Government
What should you do if the person you are speaking with changes?
Content ID : CMS-2-028920
HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS
STOP and re-authenticate
What are the steps for receiving an internal (Aetna or CVS caller) warm conference/ Transfer call?
Content ID : TSRC-PROD-016401
Basic Call Handling - Greet, Warm, Cold. Call Hold and Close Call
A member with a the client code of X8576, called in with questions on why the price of their medication went up, you ran a test claim, viewed financials and in the financials you notice the member is in the gap.
What JA can assist you in explaining each stage of coverage?
Content ID : TSRC-PROD-022972
MED D - ICL, Coverage Gap, TrOOP, Catastrophic Coverage
Maintain awareness and empathy for on-hold callers. If the caller wants you to check back more often, you should do so within approximately every…
Two minutes.
Content ID : TSRC-PROD-066076
Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfer
When Warm transferring to an external organization but not limited to benefit offices and government offices (such as Medicare) when are you allowed to release PHI/PII information? Content ID : CMS-2-028920
HIPAA (Health Insurance Portability and Accountability Act) Grid - CVS
If you are speaking with the member directly, or the POA, and they give you permission, you may proactively release the member’s PHI/PII.
"Jon, thank you for your patience. I am absolutely going to get you to the right place. To make sure they understand what we need and are ready to help you, can I share your personal and medical inform
who can start or check the status of a coverage determination or a redetermination?
what WI will you find this information in?
Before beginning the process or checking the status of a Coverage Determination or Redetermination, the CCRs MUST verify they are speaking to one of the following individuals:
Compass MED D - CCR - Coverage Determinations and Redeterminations (Appeals)
After resolving the issue: Provide solutions, alternatives, and additional options, what are the next 3 steps? Content ID : CMS-PRD1-095822
Universal Medicare D - Consultative Call Flow (CCF) Process
Recap the call.
Include why the member called
The information you provided to the caller
What was done for the member and the turnaround time (i.e., New RX Request, EPA request, etc.).
Note: Remember that the member may not know what a specific form or request is so you should explain exactly what these processes are using words that a member can understand. (i.e., instead of saying “I submitted a new rx request” you can say “I sent a request to your doctor’s office for a new prescription.”)Closing:
Utilize the client-specific custom closing if there is one indicated in Compass or the CIF.
Thank you for calling. It’s been a pleasure speaking with you, have a great day! Documenting the Call:
It is important to confirm the documentation (system generated or manual) includes the reason for the call, action taken by CCR/member and next steps while on the call.
A member calls in with Client code X8575, and stated they wanted to use Accu-Chek Guide Test strips but having trouble getting the test strips covered at the local pharmacy. After viewing the CIF, what would be your next steps?
Advising the caller OneTouch by Lifescan is the preferred covered blood glucose meter and test strips for DSNP members. The plan allows coverage for lancets (any brand) and OneTouch Test Strips up to:
· 100 test strips for members with Diabetes who are not using insulin every 90 days OR
· 300 test strips for members with Diabetes who are using insulin
An override will be needed and should be entered to pay under Part B at $0 copay
Do not ask permission to place a caller on hold, instead ask what they prefer you to do during the hold. Explaining the reason for the hold also helps to reassure the caller that the time is purposeful and not just a delay.
What is the appropriate verbiage?
Content ID : TSRC-PROD-066076
Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfer
I definitely want to ensure we have an accurate answer for you. I will need to place you on a brief hold while I work to resolve this. May I check back with you in about 5 minutes, or would you prefer I check back sooner?
A beneficiary wife, Sarah, calls in to place an order for metformin, as you get to the end of the call Sarah wants to change the payment method and delete the old one how would you proceed? ( In the call you verify there is NOT a POA on file)
A. Update the payment method like the caller asked
B. Inform the caller that "due to HIPPA I am unable to change the payment method
C.Inform the caller that we are able to add a one time at this time however to delete a payment method we have to either get the member on the line to ask permission or the member will have to call us back
C.Inform the caller that we are able to add a one time at this time however to delete a payment method we have to either get the member on the line to ask permission or the member will have to call us back Content ID: Cms-2-028920
HIPAA( Health Insurance Portability and Accountability Act) Grid- CVS
A Member called in with the client code of X8626 and asked for advice on a letter that was received, they said they needed a Prior approval. You run a test claim that confirmed a Reject 75. AFTER BRINGING UP THE CIF What would you do?
A. Offer to start a New RX request
b. Offer to initiate the PA on behalf of the member
C. Get the member over to the plan
C. Get the member over to the plan PER CIF
Content ID : CMS-PRD1-114275
Indiana University Health Plans Medicare D
An account wellness check is when you view the member’s account for potential issues.
What are some places you may view to check for these potential issues ?
How often do you perform account wellness checks?
What WI will you find this information?
HINT: Call Flow
2. On EVERY call
3. Content ID : CMS-PRD1-095822
Universal Medicare D - Consultative Call Flow (CCF) Process
A member calls in with Client code X22MZ, and it is clear the caller’s needs have been addressed after viewing the CIF, How should you close the call?
Custom Closing Statements:
If there is nothing else that I can assist you with, be aware you may receive a survey in the next day or two regarding your call experience today with me. Have a great day and thank you for calling. [PAUSE]
OR
If we have taken care of everything today, you may be contacted within a day or two to take a survey about your call experience today. Thank you for calling and have a great day.
After a total hold time of five (5) minutes, what are the 3 things that need to be done with the caller?
Content ID : TSRC-PROD-066076
Compass - Basic Call Handling – Opening the Call, Call Hold, Warm and Cold Transfer
a. Notify your caller that the department you are trying to reach is experiencing a longer than expected hold time and apologize for the wait.
If the CIF states to warm transfer the caller, then follow the instructions of the CIF.
b. Provide them with the hours of operation and the applicable phone number (Do not provide internal phone numbers to the caller).
c. Provide the option to call back at a time that is more convenient for them.
You received a call from a CVS Caremark Commercial Representative transferring a member over what information can you release to the commercial rep?
A. Since it's a CVS Caremark employee, you may give the rep all information that is asked
B. You may not release information not specifically mentioned by the caller for the member
C. You may not release any information to the caller, just get the member over as soon as possible
Answer:
B.
Release only the minimum necessary information the caller is requesting for the member
Please refer to Content ID: Cms-2-028920
HIPAA( Health Insurance Portability and Accountability Act) Grid- CVS
You receive a call from super sweet member, Yolanda, with Client Code X20AA. Yolanda wants to place a new card on file for MOR service. Upon answering, this member just melts your heart. She’s so kind. She tells you how happy she is she received a live person, as she can’t stand speaking to the IVR as it never hears her and always transfers her to a rep. How should you proceed to assist? A) Apologize, file FCR grievance then, per WI Content ID : TSRC-PROD-066744Med D - Compass Grievances: CCR - First Call Resolution Documentation Templates (Health Plans)provide tips to member on how to better utilize the IVR systems
B) Deeply apologize to Yolanda and advise her that everyone seems to have that same issue.
C) Remain silent, as Alice talks, then ask how you can help her today.
D) Per WI Content ID : TSRC-PROD-066744Med D - Compass Grievances: CCR - First Call Resolution Documentation Templates (Health Plans) provide Yolanda with tips on how to better utilize the IVR system, assist the her with reason for call, then offer to get her over to her plan to discuss issues with the IVR system.
Answer: D) Per WI Content ID : TSRC-PROD-066744Med D - Compass Grievances: CCR - First Call Resolution Documentation Templates (Health Plans) provide Yolanda with tips on how to better utilize the IVR system, assist the her with reason for call, then offer to get her over to her plan to discuss issues with the IVR system and file the grievance.