Member & Provider Services
MEMBER AND PROVIDER CALL SERVICES
Member retention is more important than ever for Health Plans in the competitive government health programs market. Paraphrasing Ben Franklin, the new adage for Health Plans is…”A member saved is a member earned.” TMG Health is highly versed and experienced in dealing with the unique requirements of Medicare Advantage. Part D and Medicaid products. Based on over 10 years of experience in managing a call center dedicated to Medicare and Medicaid members, we thoroughly understand the unique types of calls and the extended duration of member and provider inquiries.
This experience has helped us to generate 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.
The effectiveness of our Member & Provider Call Services starts with TMG Health's use of a carrier-class, Oracle call center platform as the center 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 uses proprietary knowledge bases, an image database and set of rapid data capture input screens. TMG Call® integrates all of these into a single, intuitive user interface. TMG Call® facilitates our Customer Service Representatives to rapidly and accurately handle inbound and outbound calls through fingertip availability of information, scripting and FAQs.
Key services provided by TMG Health can include the following:
FOR MEMBERS:
- Outbound Education Verification calls
- New member orientation/welcome calls
- Telephonic HRA and WAS/MSP calls
- Member inquiries including:
- Benefits
- Eligibility
- Premium Billing
- Claims Status
- Advanced determination of benefits coverage
FOR PROVIDERS:
TMG Health Customer Services is staffed during CMS-required hours (all time zones) and as mutually agreed by TMG Health and our Clients. Members and Providers call using Client specific toll free lines. TDD/TYY is supplied for hearing impaired members. Spanish speaking CSRs are staffed and translation services are available for other languages.
TMG Health will process member correspondence according to the Client's policies and procedures. We work with the Client to respond to and resolve appeals and grievances issues. 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 in accordance with agreed policies and procedures. Additional involvement in Appeal and Grievance handling is also available via TMG.
COMMITMENT TO QUALITY
TMG Health Customer Service Representatives (CSR) undergo not less than 10 weeks of training, testing and practice in preparation for handling live calls. All representatives are trained in Medicare, Medicare Advantage, Part D, 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.
Each TMG Health CSR is monitored a minimum of 10 times per month using both taped and live call monitoring techniques. A score card is used to determine CSR skills and efficacy and measures interpersonal skills (call presentation, greeting, closing and call handling), knowledge, call documentation and HIPAA skills. A CSR must meet a rating of 90 out of 100 in order to meet expectations. HIPAA verification must occur 100% of the time for every call.
HEALTH RISK ASSESSMENTS AND PROCESSING
TMG Health performs the following Health Risk Assessment and processing services:
- Initial and 2nd Mailing as needed
- Phone contact to survey non-respondents after 2nd mailing
- Health Risk Assessment data capture
- Optional Telephonic Surveys
TMG Health utilizes a three-part health risk assessment process in order to meet the CMS requirement that plans make a good faith effort to assess all new enrollees within 90 days of their effective date. Non-respondents are followed up 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 images all forms received.
TMG Health's risk assessment and processing is managed in accordance with CMS standards, as well as with all Medicare/state regulations and Client's requirements.
WORKING AGED/MSP (COB) SURVEYS
Although the Working Aged Survey is no longer a CMS requirement, TMG Health can perform this service as requested including initial survey and follow up. TMG will also send a MSP (COB) letter upon processing of the member enrollment to verify the MSP (COB) information contained on file. TMG will send out the letter on an annual basis after the initial correspondence is sent.
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 success. We are exclusively dedicated to the government health programs market and have over ten years of experience. This extensive experience means we deliver proven, valuable, quality driven member and provider services geared to protect your brand and retain your members.
