Automated Voice Response Eligibility Verification Subsystem Call Flow Manual
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Section 4 - Third Party Liability VerificationA Third Party Liability (TPL) transaction can be made from the Main Menu or from the submenu of a Member’s response indicating TPL information is available. If the user inquires on a TPL from the Main Menu, the call flow will begin at Step 18.0. If the user inquires on a TPL from the submenu, the system will continue the call flow at Step 22.0. STEP 18.0 – Obtain INQUIRY ID For TPLTo obtain Third Party Liability information from the Main Menu, the user must enter a valid 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 19.0. STEP 19.0 – From DOS For TPLWhen 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 beyond (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 20.0.
STEP 20.0 – To DOS For TPLWhen 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-365). 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 20.5.
STEP 20.5 – TPL Host TransactionSince the TPL information resides at the host, the system sends a transaction to the host to request TPL 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 will provide up to 5 TPL insurance carries per Member. The system checks the response received from the host to determine whether or not the Member has other insurance information. If the Member does not have insurance, the system continues the call flow at Step 21.0. If the Member has at least one insurance policy with another insurance company, the system continues the call flow at Step 22.0.
STEP 20.7 – Member Not On File For TPLIf 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 2.0 Menus for Providers..
STEP 21.0 – No TPL Found For MemberIf the Member does not have an insurance policy with another insurance company, the system informs the user as follows: “The member has no 3rd partly liability coverage, and” “The Member is not insured by another carrier.” The call flow is continued at Step 24.2 for TPL Continue Menu With Name Option. STEP 22.0 – Number Of TPL CarriersFor Members with other insurance carriers, the system first informs the caller of how many insurance carriers the Member has with the following message: “The Member has insurance policies with (NUM-OF-CARRIES) carriers.” The system then proceeds to Step 23.0
STEP 23.0 – TPL Information ResponseThe system tells the user the company name for a Member’s other insurance carrier. “The Member has an insurance policy with (COMPANY NAME) with policy number (POLICY NUMBER) from (FROM-DATE-OF-SVC) through (TO-DATE-OF-SVC).” If the system has spoken information for the last or only insurance carrier, the system continues the call flow at Step 24.2 for TPL Continue Menu With Name Option. If the system has information for another insurance carrier, 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-OF-REMAINING) carrier/carriers remaining. To hear information for the next insurance carrier, press 1. To skip the remaining carrier information, press 2.” If the user presses 1, the system resumes the call flow at step 23.0. If the user presses 2, the system resumes the call flow at Step 24.2 for TPL Continue Menu With Name Option. The system will speak 3 TPL segments and on the 4th segment the system will provide the user with the following options: “There is/are (NUM-OF-REMAINING) carrier/carriers remaining. For assistance from a Customer Service Representative, press 0. To skip the remaining carrier 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 24.2 for TPL Continue Menu With Name Option.
STEP 24.0 – TPL Continue MenuAt this point the system has completed the TPL information. The user may now do another TPL inquiry or return to the Main Menu. The system prompts the user accordingly. “To inquire on another Member’s Third Party Liability information, press 3. 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 3, the system resumes the call flow at Step 18.0. 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 24.2 – TPL Continue Menu With Name OptionAt this point the system has completed the TPL information. The user may now hear the Member’s name, do another TPL inquiry or return to the Main Menu. The system prompts the user accordingly. “To hear the Member’s name, press 6. To inquire on another Member’s Third Party Liability information, press 3. 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 6, the system resumes the call flow at Step 25.0. If the user presses 3, the system resumes the call flow at Step 18.0. 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 25.0 – Member Name For TPLThe 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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