Enrollee Services. 2.10.1 Enrollee Service Representatives (ESRs). The Contractor must employ ESRs trained to answer inquiries and concerns from Enrollees and Potential Enrollees, consistent with the requirements of 42 C.F.R. §§ 422.111(h) and 423.128(d) as well as the following requirements:
Enrollee Services. The MCMIS shall electronically support all of the enrollee services as specified in Article 5 and Article 9 of this contract. The system shall:
Enrollee Services. A. Written Materials The Contractor shall unless otherwise provided in this Contract, ensure that all written materials provided by the Contractor to Enrollees:
Enrollee Services i. A description of all available Coordinated Care covered services, including EPSDT and other preventive services, and an explanation of any service limitations, referral and prior authorization requirements. The description shall include the procedures for obtaining benefits, including family planning services, from out-of-network providers.
Enrollee Services. Enrollee Service Representatives (ESRs) The Contractor must employ ESRs trained to answer Enrollee inquiries and concerns from Enrollees and Eligible Beneficiaries, consistent with the requirements of 42 C.F.R. § 422.111(h) and 423.128(d) as well as the following requirements: Be trained to answer Enrollee inquiries and concerns from Enrollees and prospective Enrollees; Be trained in the use of TTY, Video Relay services, remote interpreting services, how to provide accessible PDF materials, and other Alternative Formats; Be capable of speaking directly with, or arranging for an interpreter to speak with, Enrollees in their primary language, including American Sign Language, or through an alternative language device or telephone translation service; Inform callers that interpreter services are free; Be knowledgeable about MassHealth, Medicare, and the terms of the Contract, including the Covered Services as referenced in Appendix A and defined in Appendix B; Be available to Enrollees to discuss and provide assistance with resolving Enrollee Complaints; Have access to the Contractor’s Enrollee database, EOHHS’s Eligibility Verification System (EVS), and an electronic provider directory; Make oral interpretation services available free‑of‑charge to Enrollees in all non‑English languages spoken by Enrollees, including American Sign Language (ASL); Maintain the availability of services, such as TTY services, computer‑aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified interpreters and other services for Deaf and hard of hearing Enrollees; Demonstrate sensitivity to culture, including disability culture and the Independent Living Philosophy; Provide assistance to Enrollees with cognitive impairments; for example, provide written materials in simple, clear language at a reading level of grade 6 and below, and individualized guidance from Enrollee Services Representatives to ensure materials are understood; Provide reasonable accommodations needed to assure effective communication and provide Enrollees with a means to identify their disability to the One Care Plan; Maintain employment standards and requirements (e.g., education, training, and experience) for Enrollee services department staff and provide a sufficient number of staff to meet defined performance objectives; and Ensure that Enrollee Services Representatives make available to Enrollees and Eligible Beneficia...
Enrollee Services. Insurer shall maintain an enrollee service unit to provide enrollee-related customer service. The enrollee service unit shall have the ability to answer Enrollee inquiries by telephone, electronic communication and written communication. The enrollee service unit shall be accessible by a toll-free telephone number during the hours of 7:30 a.m. to 7:30 p.m. Eastern Time, Monday through Friday, except on state-recognized holidays. Insurer shall utilize automatic call distribution equipment and enrollee services representatives staffing sufficient to handle the expected volume of calls. Insurer shall also provide a telecommunication device for the deaf (TTY/TDD) and access to interpreter services. Insurer shall ensure enrollee services representatives are satisfactorily trained and capable of resolving Enrollee and potential Enrollee inquiries in all areas related to Florida Healthy Kids. Insurer’s enrollee services representatives shall be familiar with the basic eligibility requirements for the Florida Healthy Kids Program, but shall refer or transfer individuals with detailed questions or concerns to the Florida KidCare call center. Insurer shall monitor the enrollee services line to ensure Insurer meets certain performance standards and for quality assurance, including recording calls, conducting routine audits and other monitoring activities. Insurer shall meet the performance guarantees related to enrollee services included in Attachment C. Insurer shall provide a nurse line staffed by licensed nurses and available to Enrollees twenty- four (24) hours per day, seven (7) days a week. The nurse line shall provide health education and assist Enrollees in determining which place of care (e.g., urgent care center, emergency department, PCP office) is clinically appropriate for the symptoms described. Insurer shall also provide a behavioral health crisis line staffed by licensed professionals and available to Enrollees twenty-four (24) hours per day, seven (7) days a week. The behavioral health crisis line may be provided as part of the nurse line or separately. If the behavioral health crisis line is part of the nurse line, all licensed nurses must be trained appropriately. Insurer shall provide a publicly available website with access to Florida Healthy Kids information. The publicly available website shall include:
Enrollee Services. Materials, processes, infrastructure (e.g., call center), and functions offered by the Contractor to provide information and support to Enrollees and Eligible Beneficiaries and respond to inquiries and concerns raised by Enrollees and Eligible Beneficiaries about the MMP, including, but not limited to, benefits, policies, processes and/or Enrollee rights.
Enrollee Services. 2.9.1. Enrollee Service Representatives (ESRs)
Enrollee Services. A. Enrollee Rights
Enrollee Services. Subject to the terms of this Agreement, Pharmacy agrees to accept all Enrollees as customers at all pharmacies operated by Pharmacy and to provide each Enrollee all Covered Services to which such Enrollees is entitled under the terms described in Exhibit A. Pharmacy shall verify by means of the Designated Claim Adjudication System the eligibility of each person who presents as an Enrollee. Pharmacy agrees that it has the sole responsibility for verifying the eligibility of Enrollees and obtaining payment from any non-Enrollee to whom Pharmacy provides services. Pharmacy agrees that it shall not assert any claim against GUIDANTRX with respect to any losses, costs or expenses incurred as a result of or attributable to its provision of services to any non-Enrollees.
