First Call Resolution - Ownership 101
First Call Resolution - Ownership 101 Quiz
Test your knowledge on First Call Resolution and Ownership with this comprehensive quiz! Dive into various scenarios and learn how to handle member inquiries effectively and efficiently.
This quiz covers important aspects of customer service in the healthcare industry, including:
- Claim handling
- Customer assistance
- Provider communication
- Benefit explanations
We should offer benefits when a member orders an ID card.
True
False
How often should you update your open inquiries?
Every 5 days
Every 7 days
Whenever you want
Every 2 weeks
We have taken a payment from the member. What is our next step?
Close the call
Tell them to call back for their confirmation
Offer other payment options
Tell them to go online to make their next payment
When you give members PPO providers located on the website, you are required to advise the customer to check the provider's status at the time of service.
True
False
A customer is upset about an exclusion on this policy. What will we explain to the member?
The group has decided to not cover the service under their plan
This service is sometimes covered for other groups, just not yours
Refer them to their group for a possible exception
BCBS and your employer work together to determine your benefits. Unfortunately this service is not covered under your plan
A claim has rejected due to a routine diagnosis code but the member advises it was medical. We have additional medical diagnosis codes on file. What should we do? (Check all that apply)
Send the claim back with proper diagnosis codes
Offer to follow up with the member until the claim has been reprocessed correctly
Schedule a date and time to follow up with the member
Advise the member they will receive an EOB in the mail once the claim has processed route the inquiry with no callback offered
None of the above
The member's claim has rejected due to us not knowing how much their primary insurance paid. They have insurance through another company. What should we do to resolve the issue for our member?
Offer the claims fax number to have the information faxed
Advise the member that the other insurance company has to fax the information to our claims department
Advise the member that the claim will reprocess automatically once the information is rec'd.
Offer to have the information faxed/emailed directly to you
What tool can we use to determine the cost of a procedure for an out of state provider?
PAL
Google
Treatment Cost Estimator
Call the provider to ask if they know the allowed amount they usually charge for this service.
A member calls to check if their newborn baby was added to the policy yet. They updated the group on November 19th 2019 about the change. What should we do next? (Check all that apply)
Have Enrollment Services reach out to the group
Offer a callback to the member with a date and time to keep the member updated.
Contact Enrollment Services to see if the file has been received
Advise customer they will have to wait a few more days for the group to update their records
You do not have to follow up with the customer.
Advise the member that the information has not been received and refer them back to the group
A member calls to check if their spouse was added to the policy yet. They updated the group on December 11, 2019 about the change. What should we do next? (Check all that apply)
Have Enrollment Services reach out to the group
Offer a callback to the member with a date and time to keep the member updated
You are not required to follow up with the member
Advise the member to allow 10 business days for the update to take place
Advise the member that the information has not been received and refer them back to the group
We have a rejected claim and the member advises that the diagnosis is incorrect. What should we do next?
Offer to call the provider's office to confirm the diagnosis code
Advise the member that this is what the provider has submitted to us for processing.
Explain to the member the claim has processed correctly per their benefits.
A member calls due to their Point of Sale drug claims being rejected. We have authorizations in the RX/POS tab. What should we do? (Check all that apply)
Educate the customer by explaining authorization numbers are required for POS drugs
Explain to the customer they have to file the claims with the authorizations again through the website because we cannot process them over the phone.
Send the claims to be processed.
Advise that we will send them a point of sale claims form and they should send the form back to be reprocessed correctly.
A member calls due to their Point of Sale drug claims being rejected. We do not see any authorizations on the RX/POS tab. The pharmacy is participating. What do we need to do? (Check all that apply)
Advise that we will send them a point of sale claims form. Once the pharmacy has run the drug, they will need to fill it out and return it to our claims dept.
Offer to call the pharmacy and have them re transmit the medication to us
Once the authorization numbers are added, route an inquiry to have the claims reprocessed
Use Prime Prod 01 to determine if the drug was run under the member's insurance
ITS claim: A claim was submitted to us by the local plan with a provider class of "3" for non participating. We reached out to the local plan to confirm the provider is participating. What should we tell the host plan?
Ask the host plan to transmit an adjustment with the corrected provider class
Advise the member they should ask their provider if they are in network prior to the services to avoid this issue
Customer is receiving a bill for a claim that has already been paid. What can we do to resolve the issue?
Advise the member the claim has been paid and offer to send an EOB
Advise the member they will need to contact the provider and advise this has already been paid & close the call
What else am I supposed to do?
Offer to contact the provider to provide more information
The member is planning to have services rendered but is unsure of the code. They have an appointment on Tuesday but you cannot locate the service/code. What should we do?
Advise the member we need the procedure/diagnosis codes in order to quote benefits
Offer to contact the provider's office for the procedure and diagnosis code
Quote general beenfits
Advise the member to contact the provider's office to obtain the code so that we can give the correct benefits
The member's provider suggested that they have a surgery in the upcoming months, but you are unable to locate the codes for the member. What should you do?
Determine the type of service that will be provided and quote general benefits
Advise the member that we will need procedure codes to quote the correct benefit
Offer to contact the provider's office for the procedure and obtain a procedure code
The member's drug benefits are carved out to CVS Caremark, but the member is being told we handle their benefits. What can we do to achieve FCR on this call? (Check all that apply)
Offer to get someone on the line that can assist
If the customer wants your help, call the other carrier and assist in resolving the issue
Warm transfer the customer to the other carrier's representative
Member is awaiting a PA to be approved/denied. We have the PA on file, but it is in review. What can we do to resolve the member's issue?
Advise the member that all reviews are completed between 24-48 hours and their doctor will be made aware. So check back then.
Advise the member they will receive a letter in the mail once a decision has been made
Follow up on the status. Offer a callback to the member once a decision has been made
There is not much we can do but wait
Our member is calling to advise us that their insurance with their other insurance company has ended, but they do not know the exact date. How can we achieve FCR on our call?
Advise we will send this to our claims area to have it updated
Offer to contact the OIC to get the correct dates of the policy cancellation
Advise they will need to call back with the exact date that it cancelled
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