Automated Voice Response Eligibility Verification Subsystem Call Flow Manual

Section 8 – Service Limitations Verification

STEP 43.0 – Obtain INQUIRY ID For Service Limitations

“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.”

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 43.4

STEP 43.4 – From DOS For Service Limitations

“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 followed by a pound sign. The system edits the date to ensure it is in the correct format and is a valid, non-future date. The date must be no greater than one-year from today’s date. If the date-of-service is not a valid date, the system informs the user:

“That date is not valid. For example, July 01, 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.”

If the From 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 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 43.5.

STEP 43.5 – To DOS For Service Limitations

“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 followed by a pound sign. The system edits the date to ensure it is in the correct format, greater than or equal to the form-date-of-service, and is a valid, non-future date. It the To date-of-service is not a valid date, the system informs the user:

“That date is not valid. For example, July 01, 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-365). 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 44.0

STEP 44.0 – Service Limitations Transaction

Since the service limitations information resides at the host, the system sends a transaction to the host to request service limitations 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.”

STEP 44.1 – Member Not On File For Service Limitations

If 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 system resumes the call flow at Step 2.0 Menus For Provider.

STEP 44.2 – Service Limitations DATA

“The Member has (PROCEDURE PERFORMED) with procedure code (PROCEDURE CODE) was performed on (PROCEDURE-DATE).”

See Table 1: For more detail Procedure Code and description. For Dental, Vision, Ultrasound, Hearing, Outpatient Rehab.

This process will continue until the end of data or the limit has been reached. The limit for hearing is 5; the limit for vision is 5; the limit for dental is 5; the limit for ultrasound is 5; the limit for outpatient rehab is 5. The process will continue at step 45.0 for Service Limitation Continue Menu.

If there are no Service Limitations information returned from the host, the system replies with the following message:

“Our files show no service limitations at this time for member (MEMBER_ID).”

STEP 45.0 – Service Limitation Continue Menu

“To hear the Member’s name, press 6. To inquire on another Member’s eligibility, press 1. To inquire on another Member’s service limitation, 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 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 0, the call is transferred to a Customer Service Representative.