Member & Provider Call Services

At TMG Health, we understand the importance of brand protection and know that a responsive, positive and first call resolution-oriented customer service department is critical to your member retention and success. Based on over 10 years of experience in managing a call center dedicated to Medicare and Medicaid members, we are thoroughly versed in the unique types of calls and the extended duration of member and provider inquiries that can occur.

This in-depth experience means we deliver proven, valuable, quality-driven member and provider services geared to protect your brand and retain your Medicaid members. For example, we have developed proprietary applications and best practice-based call scripts to handle general call types. We also create plan-specific scripts relative to each client's specific product benefit structure and policies. Unique toll-free numbers are assigned to each client to support calls.

TMG Health also shares your concern for the individual Medicaid member. We are experienced in working with culturally diverse and challenged populations. We understand the access, lack of knowledge, fear, language and disparity issues that contribute to non-compliant actions. We recognize the special needs of the most vulnerable population of the poor, young, elderly, disabled and chronically ill.

We pride ourselves on responsiveness to member inquiries and requests for help, and partner with you to address your plan's specific concerns. It is this human touch, in addition to member help "touch points" and proactive "reminders" of upcoming health needs and events, that distinguishes our service and your members' experience.

TMG Call®
The effectiveness of TMG Health’s Member and Provider Call Services starts with our use of a carrier-class, Oracle® call center platform as the basis of our technical infrastructure. This connects with our managed care information system and is enhanced with our proprietary call center application, TMG Call®. This unique application integrates proprietary knowledge bases, an image database and a set of rapid data capture input screens into a single, intuitive user interface. TMG Call® allows our Customer Service Representatives (CSRs) to rapidly and accurately handle inbound and outbound calls through fingertip availability of information, scripting and FAQs.

Key call center services provided by TMG Health can include the following:

For Members:

  • Outbound Education Verification calls
  • New member orientation/welcome calls
  • HRA and WAS/MSP calls
  • Member inquiries including:
    • Benefits
    • Eligibility
    • Premium Billing
    • Claims Status
    • Advanced determination of benefits coverage

For Providers:

  • Provider Inquiries
  • Member Eligibility
  • Provider Status
  • Claims Status

 

TMG Health Customer Services is staffed during CMS and state required hours (all time zones) and as mutually agreed upon by TMG Health and our clients. Members and providers are directed to call using our client-specific toll-free lines. TDD/TYY is supplied for hearing impaired members. Spanish-speaking CSRs are on staff, and translation services are available for other languages.

Appeals and Grievances
TMG Health works closely with each client to respond to and resolve appeals and grievances issues and related member inquiries and correspondence according to the client’s policies and procedures. Appeals and grievances received by TMG Health are normally entered into our system and electronically routed to our client’s appeals and grievances units for resolution. Additional involvement in appeal and grievance handling is also available upon request.

Health Risk Assessments and Processing
TMG Health performs the following Health Risk Assessment and processing services:

  • Initial and second mailings as needed
  • Phone contact to survey non-respondents after second mailing
  • Health Risk Assessment data capture
  • Optional Telephone Surveys

TMG Health utilizes a three-part health risk assessment process in order to meet the CMS requirement that Medicaid(?) plans make a "good faith" effort to assess all new enrollees within 90 days of their effective date. Non-respondents are followed up on with a second mailing and then phone contact. While TMG Health has the ability to implement and score the PRA+, we will implement any tool that the client requests (subject to third-party licensing costs). TMG Health also images all forms received.

TMG Health's risk assessment and processing is managed in accordance with CMS standards, as well as with all Medicaid/state regulations and the client’s requirements.

Commitment to Quality
TMG Health Customer Service Representatives undergo not less than 10 weeks of training, testing and practice in preparation for handling live calls. All representatives are trained in, senior sensitivity, cultural sensitivity, call protocols, documentation, and much more. New agents are quality monitored by a dedicated Customer Service Quality Department at high levels until proficiency is demonstrated. All calls are digitally recorded and can be made available to clients upon request.

Each TMG Health CSR is monitored a minimum of 10 times per month using both taped and live call monitoring techniques. A scorecard is used to determine CSR efficacy and measure interpersonal skills (call presentation, greeting, closing and call handling), knowledge, call documentation and HIPAA skills. A CSR must maintain a rating of 90 out of 100 in order to meet expectations. In addition, HIPAA verification must occur on each and every call.