Waiver Verification Training Training and Development Staff Guide 1
COURSE OBJECTIVE Upon completion of this course, staff will know how to effectively handle waiver verifications and associated inbound and outbound calls, in support of CHP s Waiver Verification process. SUPPORTING OBJECTIVES Staff will know how to handle Waiver Verification by following the guidelines below: Navigating Spartacus to accept, decline, or skip waivers Accepting or declining waivers when confirming benefits Utilizing phone etiquette tips provided Logging in to waiver queue to handle incoming waiver calls o HIPAA, Login Questions, Waiver Approvals, Waiver Denials, International Waivers 2
WAIVER VERIFICATON OVERVIEW Staff will be responsible for Waiver Verification and the associated customer service during each enrollment period. Many colleges and universities require that all full-time students have adequate health insurance coverage. If students cannot provide proof of such coverage, they will automatically be charged for the student health insurance. This charge will be placed on their tuition bill. Students waiving the insurance must document proof of coverage. Verification is done via a real time electronic data interchange (EDI) with Dorado to verify coverage exists. Waiver results will be displayed back to the member within 15 seconds. (Approved or Pending) See Student Insurance Waiver Verification Guideline for specific process Student Insurance Waiver and Enroll Process Students are given the opportunity to waive the insurance during the Fall, Spring, and/or Summer open enrollment periods. 3
HIPAA What is HIPAA? Health Insurance Portability and Accountability Act of 1996 It is a broad federal law that addresses many health care privacy, security and electronic billing issues; impacting health care providers, carriers, clearing houses, employers with self-funded plans and other business associates. Our focus is to protect member information. While this course focuses on waivers it is important to only share the minimum necessary information with callers. Let the caller advise you of the members information such as student id #, email address, date of birth etc You can give hints but should not give out personal member information. Examples: Can say.edu email address or gmail account but do not give out the full email address Can advise starting number or letter of school id 4
TELEPHONE ETIQUETTE The following are some important tips to use each day. Speak clearly: You may be nervous with your first few calls. Remember to speak slowly and clearly so the person on the other end can understand you. Listen closely: Remember that your listening skills are just as important as speaking. This will reduce the number of times you have to ask someone to repeat what they have already said. Avoid food or beverage: From time-to-time we all try to slip a sip or bite in while we sit on hold. Please avoid doing this so you are not caught off guard when it is time for you to respond. Minimize any background noise whenever possible Please keep in mind you will be contacting insurance companies and it is common to be transferred multiple times throughout a call. For incoming calls, you will be dealing with students who this may be their first encounter with Health Insurance. Sometimes this becomes frustrating. You should avoid showing any frustration to the person on the other end of the line. 5
WAIVER VERIFICATION INBOUND CALLS Logging into Queue Your phone will have a Waiver button which must be selected to log into the queue. Primary Call Center Agents - Waiver Logging In and Out: To log into ALL OF THE call center group(s) that you have access to: Find the programmed WAIVER Login button. Both the green and red LED s will be dark. Press the ACD Login button. The GREEN LED lights up, to show you ve joined your group(s), as well as G on the phone display screen; you will start receiving calls directed to all of the group(s) you re pre-designated to join each day. To log out of the call center group(s): Find the programmed WAIVER Login button on the home screen of the phone. The GREEN LED should be lit to indicate you are logged into the call center group(s) presently. Press the group Log-in button. The button s GREEN LED goes dark. 6
WAIVER VERIFICATION INBOUND CALLS (cont) Making yourself Busy/Not Available By default, the next call in queue will not be presented to your phone until after a short period of busy wrap-up time following your previous call center call. In the event you will need to extend the length of time before you can take the next call in queue, use the programmed DND button. To Enable: Press the programmed DND button. The GREEN LED lights up, and an N appears after your name on your display screen. You will still receive calls from other users, as well as any direct calls transferred to you by another user or the corporate auto attendant. You can still use the phone to make outgoing calls; when you go off-hook you will hear stuttered dial tone. To Disable: Press the DND button again. The GREEN LED goes dark. Waiver Queue Voicemail Retrieval: Voicemail must be checked daily and returned within 1 business day. To check the voicemail hit *17 on your phone. Enter extension 303# password #. You will be presented with an indication of new/old/saved messages. Follow the prompts to listen to the voicemails. Use the up and down arrow keys to highlight which type of messages (New, Old or Saved) you want to listen to, and press Select or OK key, or the adjacent feature key. The details of the first message of that type are displayed. 7
WAIVER VERIFICATION INBOUND CALLS (cont) HIPAA Keep in mind when receiving calls from students/parents, this may be their first experience with not only Student Insurance, but the waiver process. We also need to remain HIPAA compliant, so we will not give out personal information to anyone except the covered student. Inbound Call Scripting Proper Greeting/Opening: Good Morning/Good Afternoon. My name is (First Name Only). To whom am I speaking with? If not member, what is your relationship to the member? - If caller is the Insured: Thank you. Please verify your school, How may I help you? - If caller is a Parent/Spouse/3 rd party: You can assist with waiver but cannot give out any personal or information about the member. Proper Closing: Thank you for calling CHP Call Queue s Waiver X 303 Schools X 301 NYU X 305 Large Schools (JHU, Umass, UNLV, UW-Madison) X 311 Employer Group X 309 8
WAIVER VERIFICATION INBOUND CALLS (cont) How to view Waivers Denied Waivers If a waiver is denied, the denial reason is added to the auto email sent to the student. The student is then able to update their waiver through their online account. Once the waiver is updated it will move back in to Pending status for review. You can also view the reason for the denial in the students account by clicking the declined link under the Enroll Status column. Waivers take 3-5 days to process (deny or approve) for Domestic students, and longer for International students. International students need to send a copy of their plan s Benefits and Exclusions to waiver@studentinsurance.com for review. Login Questions If a student needs help logging in first make sure they are in our system. They may need to create an account or submit waiver first. If they have an account, go to their account under the Spartacus tab and select reset account password. Then direct them to the login page for their school and select the create new account option. 9
WAIVER VERIFICATION OUTBOUND CALLS Waiver Verification for insurance that cannot be done via Dorado is done telephonically. You will be responsible for making outbound calls to various insurance companies to verify students have adequate coverage. With this function comes the responsibility of professional phone etiquette skills. Waiver Verification callers will be assigned a school(s) within a specific state in which they will make calls to verify coverage. Spartacus is the system that is used to obtain work each day. During the verification process you will have the option to accept, decline, or skip coverage. Telephone calls could be recorded and monitored so it is important that you make the proper selection regarding coverage, as audits will be performed on random students. There are some important tips to remember as you place calls to each insurance company. We are not calling from a provider s office. We are the insurance company. When you reach an automated system, select the member option, not the provider option. When a representative answers, explain that you are not the member, but calling from the insurance company. We are verifying medical eligibility only. We do not need specific benefit information. The insured does not have coverage with us. We administer student insurance for the university that the insured is attending. The insured is opting to waive our coverage, so we are verifying that he/she has other insurance. 10
WAIVER VERIFICATION OUTBOUND CALLS (cont) SAMPLE CALL SCRIPT The call script below can be used to help you navigate through the verification calls. It is not required that you follow these scripts verbatim, but this sampling provides you information you are likely to be asked during your call. You will be listed as the Waiver Verifier in the example listed below: Insurance Company: Thank you for calling Acme Insurance. Are you the member or a provider? Waiver Verifier: My name is Jane; I m calling from an insurance company to verify medical coverage/eligibility. Can you please provide the effective and termination date (if any) of the insurance Insurance Company: What is the name of your company? Waiver Verifier: Consolidated Health Plans. (If asked, the Tax ID number is 04-3187843 and the return telephone number is 877-657-5030.) Insurance Company: Does the member have coverage with you? Waiver Verifier: No, we administer student health insurance to the university that the member attends. He/she has opted to waive our coverage. 11
WAIVER VERIFICATION OUTBOUND CALLS (cont) Insurance Company: We show this member has had active medical coverage/eligibility since 1/1/2012. Waiver Verifier: Can you confirm there is coverage outside the home state? Insurance Company: Yes. Waiver Verifier: Thank you COMPANY INFORMATION As you verify waivers, the insurance companies you contact will ask a series of questions before they agree to release information to you. Company Name: Consolidated Health Plans Company Type: Insurance Company Federal Tax ID: 04-3187843 Telephone Number: 877-657-5030 12
WAIVER VERIFICATION PROCEDURES The following criteria will advise you when each should be selected. ACCEPT WAIVER The waiver will be accepted when you are able to confirm the student has active coverage, for the coverage period they request to waive from, with the insurance company you contacted. DECLINE WAIVER The waiver should be declined when you are unable to confirm the student has active coverage with the insurance company you contacted. You may run into discrepancies during your calls regarding the student s address, date of birth (DOB), subscriber/member/policy holder ID, or insurance company telephone number. Each situation may require further investigation on your part. You may have to decline or skip the waiver for the following reasons: Invalid Address An incorrect address may differ because a home address vs. a college address may be listed. Explain we are trying to verify eligibility as they are college students, and that may be the reason the address differs. In some cases, this explanation satisfies the insurance company and they will provide the verification. In the event it does not, Skip the student and indicate the reason as invalid address. 13
WAIVER VERIFICATION PROCEDURES (cont) Date of birth For inaccuracies with the date of birth, you may have two circumstances that arise. The company may state, we show Joe Student as an insured member, but that is not the DOB we have on file or we don t have anyone listed with that DOB. You may inquire as to if what we have is close and that we will get the student to update his DOB with them or us, but ask them if they show Joe Student active? If they still don t verify, Decline for Invalid date of birth for insured from the denial dropdown list. Additional wording has been added in the background to go out on the denial email stating: The DOB you gave us does not match what the insurance company has on file. Please contact your insurance company directly & resubmit your waiver. Another instance of inaccurate DOB may be when using an automated system instead of speaking with a customer service representative. If this occurs, please do not automatically decline the waiver. Speak with a customer service representative directly. It could be that the automated system did not understand your response. 14
WAIVER VERIFICATION PROCEDURES (cont) Invalid Member/Subscriber ID Number When the Subscriber/Member/Policyholder ID number is not correct, you may Decline for Invalid Insurance Member/Subscriber Number. If it is an Aetna plan, and the student uses an ID number starting with the letter W followed by only four (4) numbers, you will also Decline for Invalid Insurance Member/Subscriber Number. You should also include a note stating The 'W' and all 9 digits are needed to verify your coverage, please correct and resubmit. Please keep in mind, only Aetna ID numbers starting with the letter W should be declined for this note reason, as there are nine (9) digits in the complete ID number, and all are needed to verify the coverage. This would be one (1) time you may add a note to a student s denial. Invalid Telephone Number Do not decline any waivers for invalid telephone number without first checking the carrier telephone number handout to investigate if there is a valid telephone number available. NOTE: If the waiver was approved in the fall, please do not decline it for the spring/summer unless the policy has terminated. Please do not give the termination date in your decline reason. 15
WAIVER VERIFICATION PROCEDURES (cont) SKIP WAIVER There are times when you are unable to accept or decline a waiver. You will have the option of skipping the waiver but should use this only in specific situations: Do not contact insurance companies for international students unless you have been instructed by your manager to do so. If customer service will not provide any information because the student s address is incorrect. If you are unable to verify a Tricare policy or a Veterans Affairs policy. You should not skip waivers for long hold times, if you are unable to verify coverage due to incorrect telephone number, or if an office is closed. For hold times over five minutes, you can move to the next student and try the insurance company later in the day. The same applies to office closings. All skipped waivers should be reviewed with the Waiver Manager daily on how to proceed. 16
SPARTACUS Work will be managed a program called Spartacus. The following information will walk you through the steps necessary to pull a student and either accept, decline, or skip a waiver. Spartacus is a web-based application. A username and password will be provided to you for access into the system. System Login Once you have logged into the system; a system home page will be displayed. 17
SPARTACUS You will access your work through the Waivers tab. Home Page 18
SPARTACUS Select Verify Your work will be assigned to you by state and then by university which can be selected from the drop down. 19
SPARTACUS College drop-down display 20
SPARTACUS After you choose the state and college to work, you will see a screen that allows you to select criteria for your search. After you have completed your search criteria, you will hit the submit button to proceed. Be sure your Insurance Co lists ALL and Show ALL is checked. To do multiple verifications for one carrier, sort by phone number from the Order By drop-down selection tool above. Search criteria display The performed search will then display a list of students in which you will be responsible for working. This page displays a list of students that you will be calling for waiver verification. You should work the oldest first highlighted in gray, with the exception of items that are displayed in yellow (skips) or red (previously declined). If there are any yellow or red items, work on those first. Because these items were previously received, you will work those first. 21
SPARTACUS Skipped/Declined student display Accept, Decline, or Skip The screen shot below shows the list of students with an Accept, Decline, and Skip button to the right. TIP: If the insurance company requests the insured s mailing address, you can find this information by clicking the decline button. You should then click back to return to the waiver screen. 22
SPARTACUS Accept Confirmation For calls that you are able to verify alternative coverage, you will accept the waiver by selecting the Accept button. A pop-up message will appear asking you to confirm the selection. 23
SPARTACUS Decline Reason Should you decline the waiver, you will be asked to provide a reason the waiver was declined by selecting in the Reason drop-down box. You should always use a reason provided whenever possible. Should none of the reasons apply, you will have the ability to use the freeform Notes field. 24
SPARTACUS Decline Reason Remember if you type a decline reason in the Notes field under the Reason other, be sure the spelling and grammar are correct. The student and their school will receive this denial reason. Free Form denials should be limited and only used if you feel comfortable with your reason. 25
SPARTACUS Skip Reason Skip Confirmation You will also have the option of selecting skip after contacting an insurance company. When you do so you will again need to provide a short reason and then confirm the skip before proceeding. You will continue to proceed through the list of students until you have reached the end of your assignment. 26
SPARTACUS CONFIRMATION EMAIL As part of the waiver verification process, a confirmation email will be sent to the student who has opted to waive insurance. The intention of the email is to inform the student of the status of their waiver verification. Notice will be made confirming the waiver has been accepted, denied, or pending, and for what reason, if applicable. The confirmation email can also be viewed in the communication tab in the student s account. 27
International Waivers Plans that can be allowed for International Waivers Every school has its own International waiver requirement and verifying waivers must be on a per school basis and not across the board. There are two (2) International student waiver plans that can be completed by the Waiver Department. These are US based plans that sell an international student individual policy, and that meet ACA compliance, and Repatriation & Medical Evacuation minimum limits. These plans can be extended and most students take coverage for the fall and then spr/sum, so this is something to keep in mind. Each school has different requirements for International student waiver, so these will need to be checked before processing International student waivers. The first acceptable plan is the ISO Student Health Insurance plan (Fig. 1), and this plan has several different policies so each plan (Group Number) must be paid attention too. The plans most acceptable are Group numbers: ISOJ01 & ISOJ02, both meet ACA compliance and the students receive a Confirmation Letter showing their coverage and date range to be covered. The second acceptable plan is the PSI Health Insurance Plan (Fig.2), this plan does not go by a Group number, but uses a Policy number which you can t always go by. You must look at the benefits and effective and termination dates. Fig. 1 ISO Student Health Insurance plan - what their Confirmation Letter looks like. Notice the Group Number and the effective and termination dates. 28
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Fig. 2 PSI Health Insurance plan - what their Confirmation Letter looks like. Notice the Group Number and the effective and termination dates. 30