Automated Voice Response Eligibility Verification Subsystem Call Flow Manual
|
|  Yüklə 0.86 Mb.
|
Section 12 – Co-Pay VerificationCo-Pay inquiry can be made from the Main Menu or from the submenu of a MEMBER response indicating Co-Pay information is available. If the user inquires on Co-Pay from the submenu, since the Co-Pay information resides at the host, the system sends a transaction to the host to request Co-Pay information. In some cases, there may be a slight delay while the system waits for the information to return from the host. The Automated Voice Response System provides information if available based on the dates entered by the provider. The system will continue the call flow at Step 65.0. STEP 65.0 – Obtain INQUIRY ID For Co-PayTo obtain Co-Pay information from the 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 a 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 Member ID the system will continue at Step 66.0. STEP 66.0 – From DOS For Co-PayWhen the system receives a correctly formatted ID, 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 67.0.
STEP 67.0 – To DOS For Co-PayWhen 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 67.5.
STEP 67.5 – Co-Pay Host TransactionSince the Co-Pay information resides at the host, the system sends a transaction to the host to request Co-Pay information. In some cases, there may be a slight delay while the system waits for the information to return from the host. “Please wait while the requested information is retrieved.” The Automated Voice Response System provides information if available based on the dates entered by the provider. The system checks the responses received from the host to determine whether or not the Member has Co-Pay. If the user enters a valid ID the system then gives back the following information: If the Co-Pay has been met, the system responds: The member is not presently subject to co-payments. This information is subject to change in the future. Please check co-payment status for future claims. If the member has physician and pharmacy Co-Pay for time frame entered, the system plays: Member (MEMBER-ID), co-pay applies for the time frame entered from (FROM-DOS) through (TO_DOS). If the member has only physician Co-Pay for time frame entered, the system plays: The member is not presently subject to physician co-payments. This information is subject to change in the future. Please check co-payment status for future claims. If the member has only pharmacy Co-Pay for time frame entered, the system plays: The member is not presently subject to pharmacy co-payments. This information is subject to change in the future. Please check co-payment status for future claims. If Co-Pay does not exist for the time frame entered, the system plays: The member is not presently subject to co-payments. This information is subject to change in the future. Please check co-payment status for future claims. Then this statement will be to play the out-of- pocket information to the caller:. “This member has accumulated (OUT-OF-POCKET-ACCUM) of the annual maximum of (OUT-OF-POCKET-MAX)” The system resumes the call flow at Step 69.0.
STEP 68.0 – Member Not On File For Co-PayIf 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 69.0
STEP 69.0 – Co-Pay Continue MenuAt this point the system has completed the Co-Pay information. The caller is given the option of inquiring on another Co-Pay, returning to the Main Menu, or transferring to a Customer Service Representative. The system prompts the user accordingly. “To inquire about another Member’s Co-Pay information, press 4. 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 4, the system resumes the call flow at Step 65.0. 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.
|