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MEMBER AUTHENTICATION HIPA

Member Authentication -Provider caller

2 kinds of Forms

. Power of attorney (POA) . Protected Health Permission (PHP)

HIPA Statement If MEMBER on the line = "It is my responsivility to protect your private health information from unauthorized disclosure"

If not Member on the line = "It is my responsivility to protect the Members health information from unauthorized disclosure"

beside the last 4 digits of the phone number that the caller is calling, need to ask if there is another best call back number. need to ask MEMBER ONLY if "have there been any changes in your contact information in the last 30 days"

Opening spiel - Acknowledgement ( Paraphrasing) AER

"Call Flow Opening Spiel"

" Hi! thank you for calling Healthfirst, my name is Dennis, how may I help you today? " I understand that you are calling regarding your (concern)" "are you caliing for yourself or for someone else" thank you for that but It is my responsivility to protect the Your/Members health information from unauthorized disclosure" can you provide me your (3 data point) full name, DOB, SSN. =thank you so much for that, I'm seing that your calling from the phone ending in last 4 digit. is this the best call back number you have? has there been any changes in your contact information for the past 30 days?

. SALESFORCE= Maintools included . MARX= to Verify eligibility of the members Medicare account . ePaces (Dual Members) =to check Members Madicaid eligibility . MHS -

I the provider called in, need to provide member

Office H78= On exchange no letter = Off exchange

Subscriber ID all numbers = On exchange With letters= Off exchange

Client ID number SF894875

If callers name is not listed in Responsible Party click case documentation and search for RP, if shown Valid RP caller can be assisted

Call Drivers

Before you request for ID card check first the Enrollment status. Confirm first the PCP (Primary Care Provider) Verify the Doctors Name and Phone

Correspondence History

Correspondence Type ID card type Product line ID card repalcement 2. Nevert received ALOB

Case Subject Case notes ID card repalcement/never recieve/ ALOB/ Standard print Mbr request ID card/ lost

= ID card replacement= time Expedited frame 4-7 days, standard request 7-10 business days max of 15 days of package delivery issuance, check also the mailing address if its correct TO request go to Correspondence, check if someone has already requested an ID, if none then request the ID. On Correspondence search ID request

Origin = INBOUND

Check Mailing Address

================================================ Primary Care Doctor Change/within 30 days

Ask this proving questions . When was the last time you saw your current PCP on file . Have you seen the last PCP for the last 48 hours . What is the reason why you want to change you PCD

Effective days is 2 days If the member cannot remember when he saw the PCP, put the date yesterday.

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PCP Change Status

. Internal Medicine . Pediatic . Grnrral Practice . Specialist = is a participating provider with a specialty other than Internal Medicine, Family Practice, Pediatrics, or General Practice. For Example: . Endocrinologist . Dermatologist

HF Action Rules

The "Member must select a PCP" message will display in the PCP information Card when a member does not select a PCP during enrollment or during their first 30-days of enrollment.

  1. A. A PCP will be authomatically assigned.

  2. Only members with active status can change their PCP on or after their effective date with healthfirst.

PCP Selection

If a future effectuated member request a PCP change prior to their effective date, refer to the enrollment status below to determine the eligibility of the change. a. If a member status is future-enrolled, the change can be made prior to their effective date. b. If a member status is pre-effectuated (not active until binder payment is made and reflected as posted.) instruc the member to make their payment before requesting a PCP change, or select on their effectuve date by any of the following:

  1. Call CCO at the number listed on the back of their ID card

  2. Visit a Community Office

  3. Visit the Member Portal

    c. Document

PCP request

Effective Date of PCP Change

a. Confirm if the member has seen another PCP within the last 48 hours to determine the effective date ot the new PCP, with the exception above(c-3). This will help to ensure providers are paid by Healthfirst and prevent the member from getting billed.

b. Prove member for the reason another PCP change is requested to include ib the docummentation

c. Call the current PCP to confirm if the member was seen and determine the effective date for the new PCP.

A PCP should not be effective and terminated on the same day as this will result in a gap in PCP history

============================================================= PCP cahnge in Salesforce . Confirm the current PCP on the file by informing member the PCP's first, last name and office address.

. Prove to confirm the reason to change the PCP. Verify if member has any restricted flag.

. note: if a foster care indicator is present on the member's account, refer the caller to their Foster Care Coordinators to change the PCP.

NEW CASE Case Type = Member Support Case Subtype= Appointment Schedulling Costumer Callback = No

Callback Number =

Request Reason=

Inquiry Type= Member will contact Provider

Comments Interaction ID Providers phone number

=============================================================== PCP change for Spacialist Escalate to Coordinate primary request form=

1 facilty with 5 doctor's example Dr. Richard can meet the MBR just make sure that the Dr. is in the same Facilty

if the mbr want to change the PCP . Check enroll status. (pre effectuated mbr need to make binder payment first) .

Denta Quest = dental vendor