Top 10 to Avoid Receiving Member Complaints

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Presentation transcript:

Top 10 to Avoid Receiving Member Complaints

1. Verify enrollee's eligibility 1. Verify enrollee's eligibility. Make sure to include enrollee's Medicare HICN number on the application. P E L L E G R I N I & A S S O C I A T E S • P A G E 2

2. Confirm enrollee's providers are participating 2. Confirm enrollee's providers are participating. Use the online search tools available to you. Providers may participate in one plan type and not another in the same area (i.e., may participate with HMO, but not PPO). Only advise if the provider or facility is or is not currently an in- network provider or facility. Do not comment that a provider/facility may participate with the plan in the future. P E L L E G R I N I & A S S O C I A T E S • P A G E 3

3. Provide and explain plan benefits, limitations, and rules including copays, coinsurance, coverage gap, and Part D penalty. P E L L E G R I N I & A S S O C I A T E S • P A G E 4

4. Verify enrollee's medication coverage on www. medicare 4. Verify enrollee's medication coverage on www.medicare.gov to determine tier level and any restrictions (i.e. prior authorization, quantity limit, step therapy). Also, explain preferred vs. non-preferred pharmacy if applicable.

5. Explain to enrollee they are not joining a supplement plan 5. Explain to enrollee they are not joining a supplement plan. Be clear that an MA plan replaces original Medicare as the primary insurer. If the enrollee has a supplement, it will not pay with this plan. Enrollment in an MA plan will not automatically disenroll an enrollee from a supplement plan.

6. Verify the election Period 6. Verify the election Period. Choose the appropriate election period for the enrollee.

7. Explain the Cacellation and Disenrollment process.

8. Ensure proper plan selection on the application.

9. Conduct a final review of the enrollment form and confirm all information is complete. P E L L E G R I N I & A S S O C I A T E S • P A G E 1 0

she is completing an enrollment form. 10. Verify enrollee understands he or she is completing an enrollment form. P E L L E G R I N I & A S S O C I A T E S • P A G E 11

Follow us to stay up to date with compliance! Just give the logos a click! P E L L E G R I N I & A S S O C I A T E S • P A G E 12