PST

MEMBER SERVICE ADVOCATE

Assist members with;

• plan enrollment assistance
• plan coverage explanation
• assistance with drug coverage
• claims and billing
• formulary and pharmacy network guidance
• plan changes and updates
• compliance and regulation adherence
• customer relationship management

MANDATORY ACTIONS

• greeting and identification
• understanding the issue
• willingness to help
• empathy and assurance
• resolution
• FCR
• recap and close

OTHER CALL ACTIONS

• monitoring disclosure
• hold
• dead air
• outbound calls
• disconnected calls
• contact information update
• potential CTM

GREETING AND IDENTIFICATION

• hello, thank you for calling CIGNA healthcare....

UNDERSTANDING THE ISSUE

• practice active listening
• paraphrase for clarity
• ask open-ended
• take notes
• use clarifying questions
• check past interactions
• be patient and empathetic

MONITORING DISCLOSURE

X Inbound caller / third party joins the call / on speaker phone / language line - interpreter calls / all outbound calls

PLACING THE CUSTOMER ON HOLD

• reason > permission > expectation
• dead air - 60 seconds

OUTBOUND GREETING

• be clear when stating your name and stating that you are calling on behalf of CIGNA
• state the monitoring disclosure to ensure compliance
• be straightforward in stating the name of the customer you are looking for

DISCONNECTED CALL In the event a call was disconnected prior to providing a resolution, you must;

• call the customer back immediately to finish the call and provide resolution to all their inquiries
• document all information about the dropped call and the callback in the account in the account notes section of they system
• if callback was unsuccessful - report to supervisor

CONTACT INFORMATION UPDATE

• be sure to remember to update the customer's phone number and ask for an alternate number as well
• update any PO Box address to physical address
• applicable to member and any authorized representatives
  • power of attorney
  • guardianship
  • conservatorship
  • one-time verbal consent during the call

POTENTIAL CTM (Complain to Medicare) PROCESS

• Frustrated customer hangs up > MS0075 - Potential CTM process > escalation line > mentor/supervisor > escalation by mentor/ sup via email

Critical Reminders;

• outbound calls cannot be used for enrollments - this is a CMS violation. If a customer wants to enroll, give them our customer service number and explain they must call us directly.
• only refer customer to Medicare if instructed by an internal resource - other Medicare referrals are not allowed.
• do not tell customers to contact social security directly; instead, guide them to their local office if needed.
• never blame MEDICARE or imply we're waiting on CMS for actions like enrollment approval or payment updates.
• avoid mentioning CMS (Centers for Medicare & Medicaid Services) as responsible for resolving customer issues during calls.

PATH TO SUCCESS

Open - open the call promptly and don't forget to state your name and verify whom you are talking to. Listen and Acknowledge - listen to the customer's request with your undivided attention. acknowledge the customer's request. Verification - follow standard PHI verification guidelines Probing - ask relevant questions. also verify information given to you to prevent errors. Resolve - after obtaining the information needed, research and resolve the customers concern or request Recap - tell the customer what you have done to ensure both parties are satisfied with the resolution Close - always make sure the member is satisfied and has no more questions