Automated Voice Response Eligibility Verification Subsystem Call Flow Manual

Section 2 – Member Eligibility Verification

STEP 3.0 – Standard Kentucky Medicaid Eligibility Vs. Newborn Eligibility Verification

Standard Kentucky Medicaid Eligibility verification refers to the process where a valid Kentucky Medicaid Member ID has been issued and either it, or the members Social Security Number is used to retrieve eligibility data. Prior to a newborn being issued a Member ID, Newborn Eligibility Verification is obtained using the Kentucky Medicaid Member ID or Social Security Number of the mother.

First the system prompts the user to specify the eligibility verification category:

“For Newborn eligibility verification, please press 4. For Standard Eligibility verification, press 5 followed by the pound sign.”

If the caller enters either 4# or 5#, they are prompted to identify if the inquiry will be by member number or social security number.

“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 had first entered 4 for Newborn, then 1 for Member Number, the system prompts for mother’s Kentucky Medicaid Member number:

“Please enter the ten-digit Medicaid Member ID of the newborn’s mother followed by the pound sign.”

If caller had first entered 5 for Standard, then 1 for Member Number, the system prompts for Member ID:

“Please enter the ten-digit Medicaid Member ID followed by the pound sign.”

The system currently edits the Member number for ten numeric digits. If the user entered a Member ID in an invalid format, the system replies:

“Member number for newborn (MEMBER–NUMBER) is invalid. Please reenter.”

– or –

“Member number (MEMBER–NUMBER). That number is invalid. Please reenter.”

If the caller had first entered 4 for Newborn, then 2 for Social Security Number, the system prompts for mother’s SSN:

“Please enter the Social Security Number of the newborn's mother, followed by the pound sign.”

If caller had first entered 5 for Standard, then 2 for Social Security Number, the system prompts for the SSN:

“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',”

After a valid inquiry ID is provided, the call flow continues with step 4.0

STEP 4.0 – From Date-of-Service (DOS) For Eligibility

“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 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 than (CURRENT-DATE - 365). Please enter the eight digit From date-of-service in month, day, century, year format.”

Once the user enters a valid From date-of-service, the system resumes the call flow at Step 5.0.

STEP 5.0 – To Date-of-Service (DOS) For Eligibility

“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 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 month, day, century, year format.”

Once the user enters a valid To date-of-service, the system resumes the call flow at Step 6.0.

STEP 6.0 – Member Eligibility Verification Response

“Please wait while the requested information is retrieved.”

When the system receives a reply from the host, it examines the response code to determine what messages to speak to the user concerning the Member’s eligibility. Based on the response code and the data returned from the host, the system continued the call flow with steps 7.0 through 12.0.

STEP 7.0 – Member Eligibility Not On Master File

“Member ID (MEMBER-ID) is not on file.”

“Newborn using mother’s Member number(MEMBER_ID) is not on file”

“Member (MEMBER_LAST) and (MEMBER_FIRST) is not on file”

If the inquiry was done by SSN, and it is not on file, the system informs the user as follows.

“ Social Security Number (getSSN) is not on file.

-or-

“Newborn using mother’s Social Security Number (getSSN) is not on file.

STEP 8.0 – Non Eligible Member

“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 12.0.A for Eligibility Continue with Name Option menu.

STEP 9.0 – Eligible Member

“Member (MEMBER-ID) is eligible for services for the date from (FROM-DATE-OF-SVC) through (TO-DATE-OF-SVC) with county code (COUNTY_CODE).”

“Member number for newborn (NEWBORN-MEMBER-ID) is eligible for services for the date from (FROM-DATE-OF-SVC) through (TO-DATE-OF-SVC) with county code (COUNTY_CODE).”

See Table 3: for complete list of county codes.

The system will then play back the benefit package that the member is enrolled in:

“The member is enrolled in the… (BENEFIT-PACKAGE).”

See Table 4: for complete list of benefit packages. If the plan brought back is not included in this list, it is spoken back using Text-to-Speech.

This statement will be given only if one of the following programs applies:

“This Member has ([partial] KenPAC coverage, Lock-in coverage, Medicare coverage, Hospice coverage, Third Party Liability, Managed Care, EPSDT and/or Co-pay applicable for the time frame entered).”

This statement will be given if the Member has a KCHIP segment for the dates entered.

“With KCHIP Phase III eligibility”

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 call flow is continued at Step 12.0.A for Eligibility Continue with Name Option menu.

STEP 10.0 – Partial Eligibility For Member

“Member (MEMBER-ID) is eligible for Medicare co-insurance and deductible payment only.”

The call flow is continued at Step 12.0.A for Eligibility Continue with Name Option menu.

STEP 11.0 – Partial Eligibility For DOS For Member

“Member (MEMBER-ID) is eligible for a portion of the requested dates from (FROM-DATE-OF-SVC) through (TO-DATE-OF-SVC) with county code (COUNTY_CODE).”

“Member ID for newborn (NEWBORN-MEMBER-ID) is eligible for a portion of the requested dates from (FROM-DATE-OF-SVC) through (TO-DATE-OF-SVC) with county code (COUNTY_CODE).”

The system will then play back the benefit package that the member is enrolled in:

“The member is enrolled in the… (BENEFIT-PACKAGE).”

See Table 4: for complete list of benefit packages. If the plan brought back is not included in this list, it is spoken back using Text-to-Speech.

This statement will be given only if one of the following programs applies:

“This Member has ([partial] KenPAC coverage, Lock-in coverage, Medicare coverage, Hospice coverage, Third Party Liability, Managed Care, and/or EPSDT applicable for the time frame entered).”

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.

This statement will be given if the Member has a KCHIP segment for the dates entered.

“With partial KCHIP Phase III eligibility”

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 call flow is continued at Step 12.0.A for Eligibility Continue with Name Option menu.

STEP 12.0 – Eligibility Continue Menu

“Please select one of the following options followed by the pound sign.”

“To inquire on another Member’s eligibility, press 1. 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 1, the system resumes the call flow at Step 3.0. 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 12.0.A – Eligibility Continue With Name Option Menu

“Please select one of the following options followed by the pound sign.”

“To inquire on another Member’s eligibility, press 1. To hear the Member’s name, press 6. For information on Service Limitations for this Member, press 8. 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 6, the system resumes the call flow at Step 12.6. If the user presses 1, the system resumes the call flow at Step 3.0. If the user presses *99, the system resumes the call flow at Step 2.0. If the user presses 8, the system resumes the call flow at Step 44.0. If the user presses 0, the call is transferred to a Customer Service Representative.

STEP 12.6 – Member’s Name

“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.