Automated Voice Response Eligibility Verification Subsystem Call Flow Manual
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Section 9 –PRIOR AUTHORIZATION / PRO Review VerificationSTEP 50.0 – Obtain Member Number For Prior AuthorizationThe user must enter a valid Medicaid Member ID. First, the system prompts the user for a Member ID. “Please enter the ten-digit Medicaid member ID number followed by the pound sign.” The system edits the Member number for ten numeric digits. If the user entered a Member number in an invalid format, the system replies: “Member number (MEMBER-ID). That entry is not valid. Please enter the ten-digit Medicaid member ID number followed by the pound sign.” If the user enters a valid Member ID, the system will continue at Step 51.0.
STEP 51.0 – Prior Authorization / PRO Reference NumberThe system then prompts the user for a valid Prior Authorization or PRO Reference Number. “Please enter the Prior Authorization or PRO Reference number followed by the pound sign.” The system edits the Member number for eight (for PRO numbers) or ten (for prior authorization numbers) numeric digits. If the user entered a reference number in an invalid format, the system replies: “That entry is not valid. Please enter the Prior Authorization or PRO Reference number followed by the pound sign.” If the user enters a valid Prior Authorization or PRO Reference number, the system will continue at Step 52.0.
STEP 52.0 – No Prior Authorization / PRO Reference InformationAt this point the information is sent to the host to retrieve the Prior Authorization or PRO Reference data. Since the Prior Authorization or PRO Reference information resides at the host, the system sends a transaction to the host to request the information. In some cases, there may be a slight delay while the system waits for the information to return from the host, so the system informs the user with the message: “Please wait while the requested information is retrieved.” If no Prior Authorization or PRO Reference Information is found, the system replies: “No Prior Authorization or PRO information was found for Member Number (MEMBER NUMBER) with Reference Number (PRO-REFERENCE NUMBER).” The system will continue at Step 53.0 for Prior Authorization / PRO Reference Continue Menu. If Prior Authorization or PRO Reference Information is found, the system replies: “The Member (MEMBER NUMBER) with reference number (REFERENCE NUMBER) has (NUMBER-OF-STAY-DAYS) Stay Days.” If more than one line item exists, used for prior authorization, the user is than given the option to hear the next item or to continue. The use may listen to up to five prior authorization line items. The system prompts: “More line items exist. To hear the next one, press 1 followed by the pound sign. To continue, press 2 followed by the pound sign.” If the user enters 1, the information for the next line item will be played. If the user enters 2, or if all the line items have been played the system will continue at Step 53.0 for Prior Authorization / PRO Reference Continue Menu.
STEP 53.0 – Prior Authorization / PRO Reference Continue MenuIf the information was not found, the user is given the option of re-entering the Member ID, re-entering prior authorization or PRO Review Number, inquiring on another Member’s prior authorization or PRO Review Information , returning to the Main Menu or transferring to a Customer Service Representative. The system prompts the user accordingly. “To re-enter the Prior Authorization or PRO Reference Number, press 1. To inquire on another Member’s Prior Authorization or PRO Review Information, press 2. To return to the Main Menu, press star 99. For assistance from a Customer Service Representative, press 0. If this concludes your call, you may hang up.” If the user presses 1, the system resumes the call flow at Step 51.0. If the user presses 2, the system resumes the call flow at Step 50.0 If the user presses *99, the system resumes the call flow at Step 2.0. If the user presses 0, the call is transferred to a Customer Service Representative.
Section 10 - Managed Care VerificationA managed care inquiry can be made from the Main Menu or from the submenu of a Member’s response indicating Managed Care information is available. If the user inquires on Managed Care from the Main Menu, the call flow will begin at Step 55.0. If the user inquires on managed care from the submenu, the system will continue the call flow at Step 55.0. STEP 55.0 – Obtain INQUIRY ID For Managed CareTo obtain Managed Care information from the Main Menu, the user must enter a valid Medicaid inquiry ID, from date-of-service and to-date-of-service. First, the system prompts the user for an inquiry ID. “Please select one of the following options, followed by the pound sign.” “To inquire using Medicaid number, press 1.” “To inquire using social security number, press 2.” “For assistance from a customer service representative, press 0. Member Number Inquiry: If the caller selected option 1, then a prompt for the Member Number follows. “Please enter the ten-digit Medicaid member ID number followed by the pound sign.” The system edits the Member ID for ten numeric digits. If the user entered a Member ID in an invalid format, the system replies: “Member number (MEMBER–NUMBER). That number is invalid. Please reenter.” Social Security Inquiry If the caller had selected option 2, then a prompt for the Social Security Number, follows. “Please enter the member's Social Security followed by the pound sign.” The system currently edits the SSN (i.e. numeric & length). If the user did not enter a valid format SSN, the system replies: “Social Security Number (getSSN) is invalid.” Then the caller is re-prompted to enter the number. Once a valid formatted SSN has been provided, the caller is then prompted to confirm the SSN that was entered. “You entered (getSSN)” “If this is correct, press 1, or to re-enter press 2, followed by the pound sign',” If the user enters a valid inquiry ID the system will continue at Step 56.0. STEP 56.0 – From DOS For Managed CareWhen the system receives a correctly formatted Member identification number, it prompts the user for a From date-of-service: “Please enter the eight digit FROM date-of-service in month, day, century, year format followed by the pound sign, or enter a pound sign only for today's date.” The user must enter the From date-of-service in a MMDDCCYY format. The system edits the date to ensure it is in the correct format and is a valid date. If the date-of-service is not a valid date, the system informs the user: “That date is not valid. For example, July 1, 1995 would be entered as zero seven, zero one, nineteen, ninety five. Please enter the eight digit From date-of-service in a month, day, century, year format.” The date must be no greater than one-year from today’s date. If the date-of-service is too old, the system informs the user: “We are unable to process dates older then (CURRENT-DATE- 365). Please enter the eight digit From date-of-service in a month, day, century, year format.” Once the user enters a valid From date-of-service, the system resumes the call flow at a Step 57.0.
STEP 57.0 – To DOS For managed CareWhen the system receives a correctly formatted From date-of-service, it prompts the user for a to-date-of-service: “Please enter the eight digit TO date-of-service in a month, day, century, year format followed by the pound sign or enter a pound sign only if the To date of service is the same as the FROM date of service.” The user must enter the To date-of-service in a MMDDCCYY format. The system edits the date to ensure it is in the correct format, greater than or equal to the From date-of-service. If the To date-of-service is not a valid date, the system informs the user: “That date is not valid. For example, July 1, 1995 would be entered as zero seven, zero one, nineteen, ninety five. Please enter the eight digit To date-of-service in a month, day, century, year format.” If the To date-of-service is a future date the system informs the user: “We are unable to process dates beyond (CURRENT-DATE). Please enter the eight digit TO date-of-service in a month, day, century, year format.” Once the user enters a valid to-date-of-service, the system resumes the call flow at Step 57.5.
STEP 57.5 – Managed Care Host TransactionSince the Managed Care information resides at the host, the system sends a transaction to the host to request Managed Care information. In some cases, there may be a slight delay while the system waits for the information to return from the host, so the system informs the user with the message: “Please wait while the requested information is retrieved.” The Automated Voice Response System provides information for up to twelve managed care segments if the provider request span dates (example 01/01/96 to 04/01/06). The system checks the responses received from the host to determine whether or not the Member has Managed Care. If the Member has one or more segments within the span dates the system continues the call flow at Step 59.0. If the Member has Managed Care for a portion of dates, the system will continue at Step 60.0.
STEP 57.7 – Member Not On File For Managed CareIf the Member number does not exist on the Member Eligibility Master file, the system informs the user: “Member number (MEMBER-ID) is not on file.” If the Social Security Number had been given as the inquiry ID, the system responds with: “Social Security Number (MemberSSN) is not on file. The call flow is continued at Step 61.0 for Managed Care Continue Menu.
STEP 57.9 – Non Eligible Member For Managed CareIf the Member is not eligible on the specified date-of-service, or the program code is ZL or ZQ, the system responds with the following message: “Member (MEMBER-ID) is not eligible for Medicaid benefits from (FROM-DATE-OF-SVC) through (To-DATE-OF-SVC).” The call flow is continued at Step 62.0 for Managed Care Continue Menu With Name Option.
STEP 58.0 – No Managed Care EligibilityIf the Member does not have Managed Care, the system informs the user as follows: “The Member has no Managed Care eligibility from (FROM-DATE-OF-SVC) through (To-DATE-OF-SVC).” The system then proceeds to Step 62.0 for Managed Care Continue Menu With Name Option.
STEP 59.0 – Span Date Managed Care EligibilityIf the user enters span dates (example 01/01/96 throughout 03/31/96) for the Managed Care eligibility, the system will respond as follows: “Member (MEMBER-ID) is eligible for Managed Care physical health in region (REGION-NUM), the managed care organizations telephone number is (PHONE-NUM).” -or- “Member (MEMBER-ID) is eligible for Managed Care behavioral health in (REGION-NUM), the managed care organizations telephone number is (PHONE-NUM).” If the system has spoken information for the last or only Managed Care segment, the system continues the call flow at Step 62.0 for Managed Care Continue Menu With Name Option. If the system has information for another Managed Care segment, it pauses to give the user a chance to record the information from the last response. The system then provides the user with the following options: “There is/are (NUM-MC-REMAINING) Managed Care segments remaining. To hear information for the next Managed Care segment, press 1. To skip the remaining segment information, press 2.” If the user presses 1, the system resumes the call flow at step 59.0. If the user presses 2, the system resumes the call flow at Step 62.0 for Managed Care Continue Menu With Name Option. The system will speak each segment and after each segment the system will provide the user with the following options: “There is/are (NUM- MC -REMAINING) Managed Care segments. For assistance from a Customer Service Representative, press 0. To skip the remaining Managed Care segment information, press 2.” If the user presses 0, the call is transferred to Customer Service Representative. If the user presses 2, the system resumes the call flow at Step 62.0 for Managed Care Continue Menu With Name Option.
STEP 60.0 – Partial Managed Care CoverageIf the user enters a span date of service (example 01/01/96 through 03/31/96) and the Member has Managed Care for a portion of the dates the user entered. The system will respond as follows: “This Member has partial Managed Care for coverage.” If the call is during provider representative hours, then the following message is spoken: “For assistance for a Customer Service Representative, press 0. To continue, press 2.” If the user presses 0, the call is transferred to a Customer Service Representative. If the user presses 2, the system resumes the call flow at Step 17.4. After the first time-out, the caller is disconnected with the hang-up message. If the call is after hours then the following message is spoken: “We’re sorry, our office is closed. We are open from 8 AM to 6PM except weekends and holidays. Please call back and we’ll be happy to assist you. To continue, press 2.” If the user presses 2, the system resumes the call flow at Step 17.4. After the first time-out, the caller is disconnected with the hang-up message. STEP 61.0 – Managed Care Continue MenuAt this point the system has completed the Managed Care information. The caller is given the option of inquiring on another Managed Care, returning to the Main Menu, or transferring to a Customer Service Representative. The system prompts the user accordingly. “To inquire about another Member’s Managed Care coverage, press 3. To return to the Main Menu, press star 99. If this concludes your call, you may hang up. For assistance from a Customer Service Representative, press 0.” If the user presses 3, the system resumes the call flow at Step 55.0. If the user presses *99, the system will resume call flow at step 2.0. If the user presses 0, the user will be transferred to a representative.
STEP 62.0 – Managed Care Continue Menu With Name OptionAt this point the system has completed the Managed Care information. The caller is given the option of hearing the Member’s name, inquiring on another managed care, returning to the Main Menu or transferring to a Customer Service Representative. The system prompts the user accordingly. “To inquire about another Member’s Managed Care information, press 3. To hear the Member’s name, press 6. To return to the Main Menu, press star 99. For assistance from a Customer Service Representative, press 0. If this concludes your call, you may hang up.” If the user presses 5, the system resumes the call flow at Step 55.0. If the user presses 6, the system resumes the call flow at Step 63.0. If the user presses *99, the system resumes the call flow at Step 2.0. If the user presses 0, the call is transferred to a Customer Service Representative.
STEP 63.0 – Member Name For Managed CareThe user will hear the Member’s name with the following message: “The Member’s last name is (LAST NAME) and first name is (FIRST NAME).” The last and first names are spoken using Text-To-Speech. The system resumes the call flow with the previous step and repeats the sub-menu.
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