CHEAT SHEET  

VERIFICATION PROCESS
  
ASK THE CALLER IF HE'S/SHE'S CALLING FOR THEIR SELF OR 
FOR SOMEONE ELSE:

MEMBER- “IT IS MY RESPONSIBILITY TO PROTECT YOUR PRIVATE HEALTH INFORMATION FROM UNATUHTORIZED DISCLOSURE” 

RESPONSIBLE PARTY / UNAUTHORIZED/ PROVIDER / CALLER OTHER THAN MEMBER 

“IT IS MY RESPONSIBILITY TO PROTECT THE MEMBER’S PRIVATE HEALTH INFORMATION FROM UNATUHTORIZED DISCLOSURE” 

 MEMBER – 3 DATA POINTS – NAME IS REQUIRED 

RESPONSIBLE PARTY – 3 DATA POINTS – NAME IS REQUIRED 

UNAUTHORIZED CALLER – 4 DATA POINTS- DO NOT INSIST ON VERIFYING THE 4 DATA POINTS AS YOU CAN ONLY RELEASE GENERAL INFORMATION. OBTAIN VERBAL AUTHORIZATION FROM MEMBER . 

NOTE: still need to provide HIPAA statement when asking for verbal consent from the member. Because HIPAA disclosure must be read verbatim to ensure the members private health info is protected from unauthorized disclosure.  

YOU STILL NEED TO ASK THE MEMBER TO PROVIDE 3 DATA POINTS ASIDE FROM THE VERBAL CONSENT. 

IMPORTANT REMINDERS: 

ALWAYS CONFIRM THE CALLBACK NUMBER” SHOWING ON THE INTERACTION NOT ON SALESFORCE” 

ASK IF THERE HAS BEEN ANY CHANGES ON THE CONTACT INFORMATION FOR THE LAST 30 DAYS. 
 
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ID CARD REPLACEMENT 

( DO NOT REQUEST ID CARD FOR PRE-EFFECTUATED MEMBER – FUTURE ENROLLED AND DISENROLLED) 

If enrolled,   

 Confirm PCP information ( NAME and ADDRESS) 

If member disagreed on the information , do not request ID card replacement instead change the members PCP 

If member agreed, click correspondence and check the correspondence History 

To confirm if there was a previous ID card request. If its still within the time frame (7 – 10 business days) Do not request ID card instead educate the member to allow time to receive the id card.  

If its more than 7-10 business days or no previous request. Proceed to request a standard ID replacement. Select ID card replacement and click the corresponding field. 

Add a short description of the request and click origin make sure that its INBOUND 

CONFIRM THE MAILING ADDRESS ( u should be the one providing the address not the member) submit the request and advise the following: 

Educate that ID Card replacement will take 7-10 business days to arrive, and Difital ID can be print out by login in to the member portal.

If there was 2 consecutive ID Card replacement , confirm the mailing address,  if mailing address is correct proceed to request an EXPEDITED request. It will take 4-7 business days,  

If the member needs medical assistance educate that they can provide their ID Number instead and they can get medical assistance even without the physical card. 

Document it as Documentation Only – Eligibility and Benefits – Member ID card – DON’T FORGET TO START DOCUMENTING DURING THE CALL. 

 

 PCP CHANGES  

PCP CHANGE- ENROLLED AND FUTURE ENROLLED ONLY 

( DO NOT REQUEST AN ID CARD OR UPDATE PCP IF ACCOUNT IS DISENROLLED) 

1) check enrollment status if enrolled proceed to the request 

2) Confirm the name and address of the PCP 

3) for enrolled member- ask 3 probing questions 

- when was the last time time you saw the current pcp? 

- Have u seen any other pcp for the last 48 hrs? 

- what is the reason why you want to change ur pcp? 

for future enrolled - 

--ask only the reason why they want to change the pcp. 

please update the effective date to first day of their coverage. 

effective date will be the same day of their enrollment period. 

  4) ASK IF MEMBER HAS A PREFFER PROVIDER 

(always look for internal medicaine , family poractice and pediatric for 19 y/old below member- skip the not accepting patients provider ) 

 - Always ask the name and address  of the PCP 

- you can also ask for the phone number or NPI (NATIONAL PROVIDER ID) 

(not all members have the doctors NPI so always ask for the name and address 

 5) Ask the member if they want the doctor to be their new pcp if yes. 

then read the information showing on screen. 

- Effective date of the change 

- Arrange a baseline physical with the new PCP 

- Provice the name and address of the new PCP 

- ID card timeframe (7-10 business days) 

NOTE: ESSENTIAL PLAN MEMBER WILL NOT RECEIVE AN ID CARD FOR PCP CHANGE REQUEST 

INSTEAD THEY WILL RECEIVE A LETTER CONFIRMING THE CHANGE OF THE PCP 

ALL THE HEALTHFIRST ID CARD HAS THE DOCTORS NAME ON IT EXXCEPT ESSENTIAL PLANS CG 

ESSENTIAL PLAN MEMBER HAS AN ID CARD BUT IT DOESNT HAVE A DOCTORS NAME ON It 

6) OFFER APPOINTMENT IF MEMBER REFUSED AND NO ATTEMPOT TO CONTACT THE PCP 

PLEASE FOLLOW THIS Documentation 

- case type:member support\case 

subtype: Appointment scheduling 

Customer requested callback : NO 

Request reason: APPOINTMENT Inquiry 

Member will contact provider directly 

comments: interaction id  

provider phone number 

7) ask further assistance - ios there anything else i can help you with today? 

8) OFFER Survey 

9) CLOSING SPIEL - MUST PROVIDE THE WORD HEALTHFIRST