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