Notes

Table of Contents

Quoting Benefits 2
Disclaimers 5
Quoting “Tier 1” Benefits 6
Quoting “Tier 2&3” Benefits 8
Response Procedure 10








































Quoting Benefits

Overview Whether the caller is a member or provider a large portion of the type of calls coming into the call center will be questions regarding a member’s benefits.
Associates are required to provide accurate information.
This can involve conducting research, using system resources, and documenting the information, all at the same time and in an efficient manner.

We will take a close look at:
• The caller
• What they are asking of us
• Then translating their requests into Health Net’s language of the services, or ‘benefits’ they may or may not have.


The Importance
of Accuracy As a CSR, you will be using the schedule of benefit on a daily basis to answer benefit questions for both members and providers. Determining the correct benefit line to quote is a very important in quoting the benefit.

If an incorrect benefit line is chosen, the wrong co-pay, coinsurance could be given or a benefit could be stated as covered when in fact there is a members responsibility $$ or % based on the members plan.
• Providing incorrect information during the call can result in Health Net accepting financial responsibility for administrative pays, or grievances, appeals and potential liability at Health Net’s end.

The ‘Caller’ There are large differences in the way that members ask questions about their ‘services’ vs. the way providers ask for a member’s ‘benefits’ or ‘coverage information’. We have already taken a detailed look at the Schedule of Benefits over the previous few days, now we will use the terms interchangeably.

Members will typically want to talk and tell their story about their medical situation and often give more information than is needed. Members may need help in finding the benefit that they really want and sometimes require an explanation about the rules of their policy and guidelines of their medical coverage. By nature members may no be familiar with the medical verbiage their doctor is using. They rely on us to translate for them.
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Quoting Benefits, Continued

The ‘Caller’ (continued)
• It is our responsibility to provide all essential information in meeting the caller’s needs, answering questions, conducting research, offering additional information, which will lead up to quoting correct benefit.

Provider calls are typically very direct in asking for the benefit information they need to know. Providers will use medical terminology that is difficult to understand or is common language in their office.
When this happens do not be intimidated and ask the Provider to clarify what they mean and ‘probe’ to determine what is needed in order to quote the correct benefit.


Members If you are not clear about what the caller is asking it is important to ask for additional information before quoting any benefits!

Members may ask any of the following:
1. Am I covered for a hospital stay?
2. Will I be covered for an x-ray?
3. My doctor wants me to go to a specialist, am I covered?
4. I need counseling services, am I covered?
5. I need to see my doctor?

Examples of probing questions to ask the member:
1. Where is the procedure being performed?
2. Is this procedure going to be performed in an inpatient or outpatient setting?
3. Is the provider trying to get an approval for services?
4. Are you in area or out of area?

Important: Good listening skills are crucial to providing excellent customer service as well as probing the caller to determine needs for a positive resolution. Guidelines and rules have to be followed when quoting benefits.

Whenever we quote a benefit we also provide a ‘disclaimer’ with our information!

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Quoting Benefits, Continued

Providers If you are not clear about what the caller is asking it is important to ask for additional information before quoting any benefits!

Providers may state any of the following:
1. I need inpatient benefits for …
2. Does this member have coverage for delivery?
3. What is their co pay for maternity?
4. What about the newborn?

Examples of probing questions to ask the provider:
1. Where is the service going to be performed?
2. Do you need authorization as well?
3. Do you have a specific CPT code and diagnosis code?
4. Is the newborn a well baby? Did they require additional hospital stay?

Important: Good listening skills are crucial to providing excellent customer service as well as probing the caller to determine needs for a positive resolution. Guidelines and rules have to be followed when quoting benefits.

Note: Whenever we quote a benefit we also provide a ‘disclaimer’ with our information!

Additional Clarification If the member’s coverage is multi-tiered plan, clarify which tier will be used before quoting any benefits.
Some phrases to listen for are:
Provider: “We are a non-contracted facility…”OON
Member: “ I received a referral from my ‘PCP’…”HMO
As CSRs we should not wait for the caller to ‘hint’ at what they are needing to know; we should take charge of the call and verify and what type of plan they have and determine what benefit level is being used!
‘… Member I see that your coverage allows you many options…’
If the caller does not know, ask clarifying questions such as:
Q- Did you receive a referral from you primary care physician?
A- Yes! - HMO

Q- Are you seeking services from a Health Net contracted provider?
A- Yes! - PPO

Q- Is this provider non – contracted?
A- Yes! - OON

Disclaimers

When to Use Disclaimers Anytime a caller is asking for a benefit (i.e. is this covered?, what is the copay?, what do I have to pay?, etc), you must determine then communicate the appropriate disclaimer to the caller!

There are three sets of disclaimers:
• Tier 1 – HMO
• Tier 2 – PPO
• Tier 3 – OON
Select from the correct group of disclaimers for the member’s plan before selecting the disclaimer.
Once that has been done, select the disclaimer itself according to the benefit.
Use the table below to determine when to use each type of disclaimer. A good rule to follow is: If a benefit has its own disclaimer, use that one. If it doesn’t have its own disclaimer, use the “General” disclaimer.

If the inquiry is regarding… SOB Benefit Category Then refer to the following disclaimer…
A member’s effective date,
who the doctor is, who the PPG is.
Eligibility Services
Eligibility disclaimer

Visit to a PCP, Nurse Practitioner, Physician’s Assistant
Office Visit
Office Visit Disclaimer

Specialist Services: dermatologist, cardiologist, oncologist
(other than a visit to an OBGYN)




Professional Services

General Benefit/Specialist Disclaimer
Services with an OB/GYN: Infertility, Pre Natal/Post Natal, Well Woman
General Benefit/Specialist Disclaimer

Mental Health (PPO/OON)
Mental Health Disclaimer

In-Area Emergency Services


Emergency Services
Emergency/Urgently Needed Care Disclaimer

Out-of Area Emergency/Urgently Needed Care Out-of-Area Emergency/Urgent Needed Care Disclaimer


Quoting “Tier 1” Benefits

It’s back to school time! Remember the report cards we used to get in high school?



On these report cards, we could get a grade of A, B, C, D or F. Remember these letters? This is the “trick” we will use in remembering how to quote benefits.

A – ‘Authorization’ The first step when quoting a benefit on the HMO tier is to acknowledge the existence of the medical group. We do that by stating;
“As authorized by the medical group …. “
• Exception: If the caller on the line is the member’s medical group or primary care physician, or if the services are emergency the opening statement is not needed.

B – Benefit Line The next step is to quote the benefit line including disclaimers. You may put this information into your own words.
Let’s take a look at an example:
“Ground ambulance. $3000 annual maximum combined with air ambulance.”

C –
Co-Payment or Co-Insurance The next step is to quote the co-payment or co-insurance. Make sure that you state the word “co-pay” or “co-insurance.”
“… is covered with a ten dollar co-pay.”
Whether you see a “$0,” or the word “Yes” on the schedule of benefits, our response is the same;
“… is covered “with % co-insurance.”
• Note: We do not use the phrase “is covered in full.”
Health Net has contract arrangements with providers; it is very rare that we actually pay claims at 100% of the billed amount. By saying “in full”, this could be misinterpreted by the provider as 100% payment of the billed amount.
When asked, we answer “at 100% of your contracted rate with Health Net.”
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Quoting “Tier 1” Benefits, Continued

Co-Payment or Co-Insurance (continued) When a benefit is not covered on the plan, you should still follow your A & B steps. However, instead of quoting the co-payment, you will say:
“… is not a covered benefit on this plan”

D – Deductible HMO plans in general may not have a plan deductible but there may be a deductible related to a specific benefit. Check for a percentage or footnote, regarding a D, for deductible.

F – Footnotes








Sometimes you will see a footnote next to the benefit line.
Example: Hospice Care.*
When you see this symbol for a footnote, go to the bottom of the page and find the matching symbol. Ensure that you read the appropriate footnote.
* Prior Authorization is required.
Note: It’s important to verify if the service requires authorization by checking the Prior Authorization List.

There are some outpatient services that indicate authorization is required on the Schedule of Benefits, however authorization requirements are waived for the procedure.

Putting it altogether When you quote a benefit on the HMO tier, it should sound something like this:
“As authorized by the medical group physical therapy is a covered benefit with a $10 co-pay”





Quoting “Tier 2&3” Benefits

Tier 2 “A” There are some differences to quoting benefits for Tiers 2 & 3.
For tier 2 benefits, our “A” takes on a new meaning:
We begin with the statement; “… as provided by a Health Net contracted provider….”

Tier 3 “A” For tier 3 benefits the member has the choice and flexibility to seek the services of any licensed provider.
We begin the statement; “… as a reminder claims are processed at a maximum allowable amount …”

C –
Co-Payment Co-Insurance- Tier 2 When quoting a Tier 2 benefit, we must advise the caller that payment is based on Health Net’s contracted rate with the provider.
• If there is a co-insurance indicated it is a shared responsibility between Health Net and the member.
• We can advise that the provider is expected to write off the dollar difference between the billed amount and what Health Net allows per the provider’s contract!
This amount should not be billed to the member.

Note: Separately, if the caller needs an estimate of what their financial responsibility will be prior to a service being performed, we can provide that information as well!


C –
Co-Payment Co-Insurance-
Tier 3 When quoting a benefit on the Tier 3, we need to advise that payment is based on Maximum Allowable Amount (MAA). If the caller is the member, we are required to explain what that means:
• Advise that the member will owe the dollar difference between what the provider billed and what Health Net allows.
• This amount is in addition to any deductible or co-insurance they owe!

D – Deductible With Tier 2 & Tier 3 plans, we must make sure that we are quoting the deductible, when necessary.
There is one important rule about deductibles to remember:
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Quoting “Tier 2&3” Benefits, Continued

D – Deductible (continued) • Tier 2 services with co-payments, will not apply to the calendar year deductible!
• Therefore, we look for the deductible when you quote a co-insurance %%% on the plan! Use the percent sign (%) as a trigger. Whenever you see this sign, you should be researching the deductible and be prepared to quote it!
Note: When there is no deductible, say “with no deductible, or the deductible does not apply!”

F - Footnote Footnotes for Tier 2&3 products are very important.
They will identify what can be included or excluded from considering deductible totals, out of pocket maximum totals, any number of exceptions.
Sometimes you will see a footnote next to the benefit line.
Example: Hospice Care.*
When you see this symbol for a footnote, go to the bottom of the page and find the matching symbol. Ensure that you read the appropriate footnote.
* Prior Authorization is required.
Note: It’s important to verify if the service requires authorization by checking the Prior Authorization List.
There are some outpatient services that indicate authorization is required on the Schedule of Benefits, however authorization requirements are waived for the procedure.

Putting it altogether – Tier 2 Here is what a benefit quote on the Tier 2 would sound like.
“As provided by a Health Net contracted provider; a specialist consultation to see Dr Smith is covered with a 20% co-insurance of Health Net’s contracted rate after the member meets their $1,000 deductible.”
• The member has met $158 of their deductible.”

Putting it altogether – Tier 3

Here is what a benefit quote on the Tier 3 would sound like.
The provider you are specifically asking to see is not contracted with Health Net.
“As a reminder claims are processed at a maximum allowable amount, specialist consultation to see Dr Smith is covered with a 40% coinsurance of the Maximum Allowable Amount after the member meets his $2500 deductible.
• The member has met $158 of the deductible.”


Response Procedure

Responding to the caller Complete all the research necessary before quoting benefits to the caller.
• Communicating this information to the caller is consistent with Health Net’s 1st Call Resolution policy.
• If a member wants to know about medical treatment regarding his/her condition, refer to them to their Physician.
The step action response procedure below will outline general benefit information:
Step Action

1. Check member’s eligibility.
• Active – move to step 2.
• Cancelled – Stop do not give any benefit information!

2. Ask the caller for the benefit information they would like. (Do not guess!)
• Check the member’s Schedule of Benefits.
• Determine the tier the member is using; T1, T2, T3 = ‘Disclaimer’

3. Determine the appropriate disclaimer to communicate.
• Eligibility, Office Visit, Professional Services, Emergency Services




4. Ask additional questions of the caller. Ask the caller, “Where is the procedure going to be performed…?”
• Determine the correct benefit line.
• Outpatient, inpatient, office, ambulatory surgical center?
• Providers only: Do you have a CPT and Diagnosis code?
• Members: Has your doctor given you a diagnosis of your condition or a CPT code by chance?
5. Determine authorization requirements.
• Check ABS to determine if the specific CPT requires authorization.
• Check the authorization listing to determine if the procedure requires authorization.




6. Communicate all additional benefit information that may be relevant to the caller’s question.
• Footnotes related to the benefit line quoted must be read
• If a co-insurance % is given to the caller; the deductible must also be given!
• OOPM should be communicated to the caller as it applies to Tier 2 and Tier 3 only.
• Explanations and limitations, additional related services, additional disclaimers


7. If the caller wants to know about another benefit, follow the same procedure.
• If the same disclaimer applies to the new benefit information given, it is not necessary to repeat the disclaimer. Advise the caller, ‘…the same disclaimer applies…’ and continue with the additional information.
8. Review /Confirm satisfaction


Document Version Control

Date Version Changes Author of changes
08/18/2010 Original OPS West Training Document Created previously Author name is not indicated on original doc.
05/02/2011 Original Document updated to reflect new screens, plan codes, KB Articles reference, links, probing questions from callers, new maternity benefits reference. Aura Elias
4/7/2012 Outlined provider vs member requests asked by the caller and follow probing questions.
Separate the specific benefits with special requirements. Anna Baker