Fall- Grievance Game

Name That

Grievance

WOW

GAME

Contect ID: TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Please send an Emoji in the chat when you have this Work Instruction pulled up!!!

WOW

Content ID: TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

What is a Grievance?

A Grievance is filed for any dissatisfaction expressed by a member or legally authorized representative.

What?

Why file a Grievance?

• When a Grievance is filed, the group or plan has a responsibility to formally research and provide resolution to the issue.
• Documenting a Grievance is important to ensuring that our clients follow regulations.

Why?

Who can file a Grievance?

Who?

• Member
• A parent on the account, a custodial parent, or a legal guardian on behalf of a minor child.
• A POA or AOR that is on the account.
• Informal Authorized Third Party- when the member has given verbal consent to speak to the caller.
• Medical Professional on behalf of member.

Filing a Grievance 2 ways

Standard Grievance:

One Day Grievance:

• You have used all your resources to educate and advise the member of the process/ benefits.
• The member may not be happy (satisfied) with the outcome, but you have provided resolution to the reason for the call.
• The member has declined additional research.

• Additional action needs to be taken on the member's behalf, and they requested a complaint/Greivance to be filed.

IMPORTANT Reminders:

• Check the CIF FIRST on EVERY call to make sure that you can file a Grievance for that client/plan.
• If the Grievance is NOT related to pharmacy benefits, warm transfer them to Medical Member Services unless CIF says otherwise.
• If the member has 2 or more issues, you must process a SEPARATE Grievance for EACH issue.

• All Greivances MUST be submitted prior to the member disconnecting the call.
• The dedicated team agent (CA-DMHC/MEDD/SRT) will file Grievances as needed.

Objective:

• We will play a sample of a call, from the caller's point of view.
• You will see a question on your screen as well as the answer choices. I will also read each out loud.
• After each question we will go over the correct answer and discuss.

GAME RULES:

• When prompted for a nickname on Blooket please ensure that you drop it in the CHAT so we know what name you picked. Please make sure it's work appropriate.
• You will have an allotted time to review the work instruction and answer the question.
• You are scored off accuracy and how long it took you to answer the question.
• Winner will get an extra 10 minute break.
• The top 3 winners of each game will receive a shoutout HAW.

Let's all make sure we are having fun and staying professional!!!

Accuracy is Key!!!

• This is a game. However, our main focus is maintaining accuracy on each and every call!
• We will be playing a game that requires you to be fast at looking at the WI and answering the questions.

• ALWAYS take your time on every call

• Use ALL of your resources to provide accurate information to the caller.

GAME TIME!!!

Make sure you are logged in to Blooket with the Game ID and nickname.

Drop your nickname in the chat please

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Name That

Grievance

WOW

GAME

Start

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 1/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #1

ANSWER-STANDARD Quality of Care-Additional action needs to be taken on the member's behalf because she is now out of medication due to Prescriber's delay in submitting the PA.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 2/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #2

ANSWER-ONE DAY The member may not be happy (satisfied) with the outcome, but you have provided resolution to the reason for the call. The member was upset with the phone system, but you were able to resolve the reason for her call.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 3/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #3

ANSWER-STANDARD NOT able to resolve the reason for dissatisfaction, any complaints requiring coaching to be completed. The member was upset that the quote didn't match anywhere close to the actual price of the Rx. A coaching is needed for the previous rep to make sure they know how to run a test claim correctly.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 4/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #4

ANSWER-NO GRIEVANCE A Grievance can not be filed because this process is not to be used for member reconsiderations for adverse decisions on medical necessity.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 5/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #5

ANSWER-NO GRIEVANCE A Grievance can only be filed by the member or a legally authorized representative. There was no authorization on file for the wife to speak on husband's behalf and member couldn't provide verbal permission.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 6/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #6

ANSWER-ONE DAY You would be able to get that member over to AHD to get her set up with mail order. However, if member doesn't wish to be transferred to AHD and is simply upset about this change then instead of an AHD Grievance you may do a Benefits One Day Grievance.

Content ID: TSRC-PROD-059441 CarelonRx When to Transfer to CarelonRx Pharmacy

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 7/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #7

ANSWER-ONE DAY There would be no futher actions that need to be taken on the member's behalf. You can explain to the member how the deductible works on her plan and go over possible cheaper options.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 8/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #8

ANSWER-STANDARD You are NOT able to resolve the reason for dissatisfaction. Member is upset with the pharmacy's staff and further actions need to be taken on the member's behalf. That could be a possible coaching to the employees.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 9/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #9

ANSWER-ONE DAY The member may not be happy (satisfied) with the outcome, but you have provided resolution to the reason for the call. The member was unhappy that she had to wait on hold for 10 mins. but now you can provide resolution to the reason for the call.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 10/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #10

ANSWER-NO GRIEVANCE The member is notified when they are enrolled in the Lock-In program. You would have to get the member over to SRT to have that PBO placed. If you get the caller over to SRT they would be responsible for submitting a grievance.

Content ID: TSRC-PROD-029406 CarelonRx Medicaid Pharmacy Lock-In Program

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 11/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #11

ANSWER-ONE DAY You have used all your resources to educate and advise the member of the process/benefit. The member may not be happy (satisfied) with the outcome, but you have provided resolution to the reason for the call. We can educate and advise mom on how to get the brand name covered.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 12/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #12

ANSWER-NO GRIEVANCE A Grievance cannot be filed. You can advise member how to get a prior authorization for the medication.

Content ID: TSRC-PROD-019081 CarelonRx New Prior Authorization (PA) Requests

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 13/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #13

ANSWER-ONE DAY We would file a One Day Grievance because the member is upset the plan doesn't cover ANYTHING. The pharmacist can submit a Grievance on behalf of the member.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 14/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #14

ANSWER-NO GRIEVANCE We wouldn't have to file a Grievance for this member. She didn't express any dissatisfaction just wanted to know why the copay went up. We will just go over the plan/benefits with the member.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario 15/15

Play

Name That Grievance

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Scenario #15

ANSWER-NO GRIEVANCE A Grievance CANNOT be submitted on behalf of the physician. The physician CAN submit a Grievance on behalf of the member.

GRIEVANCES

Grievance Summary

ALWAYS Check the CIF!!!

Remember

What is Quality of Care?

• Home Delivery Delay
• Home Delivery Lost in Transit
• Retail Rx Error
• Home Delivery Rx Error
• Incorrect Rx shipped
• Missing eligibility due to plan error
• Account not set up correctly
• Any delay in receiving their medication caused by the Pharmacy, the Prescriber and/or the Plan

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Content ID: TSRC-PROD-020308 CarelonRx Member Low or Out of Medication

Content ID: TSRC-PROD-020308 CarelonRx Member Low or Out of Medication

When To File a Standard Grievance for Quality of Care vs When Not To?

NOT File:

• Issues where the member is out of or has less than 7 days of medication, and is NOT due to an error by a Provider, a Pharmacy or the Plan.

• = DOES NOT automatically require a grievance submission.

File:

• The member is out of or has less than 7 days of medication due to an error by a Provider, a Pharmacy, or the Plan.

• = MUST have a grievance submitted.

Is This Considered a Quality of Care Grievance?

Content ID: TSRC-PROD-020308 CarelonRx Member Low or Out of Medication

• Member failed to order medication in a timely manner.
• Member's PeopleSafe account not set-up correctly.
• Member failed to follow correct steps to complete an online order.
• Member doesn't wish to pay a high copay for the medication.
• Missing eligibility due to an error by the plan.
• Member failed to update an address change when placing an order online.
• National backorder or drug shortage situations.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

What Does a Grievance Sound Like?

SUBTLE Examples:

• "This is frustrating."

• "Why do I always have to do this?"
• "Man, I've had to do this twice already."
• Sighing between statements.
• Tone of Voice

OBVIOUS Examples:

• Profanity or Yelling
• Asking to file a Grievance
• "I'm not Happy!"
• "You're not listening to me!"
• "You are the worst!"
• "Why do I even pay for this insurance!!"

NOTE:* When you have to apologize, then a Grievance is probably going to be needed.

Why Are We Not Filing Grievances?

WHY?

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Why Are We NOT filing Grievances?

Examples:

• Not confident with filing Grievances.
• Not sure WHEN to file a Grievance.
• Better to not do it at all then to get the Grievance wrong.
• Time consuming.
• So many things that we need to do while on the phone with the member.

NOTE:*Now we are getting coachings for not filing a Grievance when one should have been filed.

Content ID : TSRC-PROD-019022 CarelonRx Commercial and Medicaid: Grievances and Complaints

Judgement Free Zone!!!