Enrollee Services Sample Clauses
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 FHKC-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 publicly available website with access to Florida Healthy Kids information. The publicly available website shall include:
a. The Enrollee handbook,
b. A printable provider directory,
c. A searchable electronic provider directory,
d. A link to FHKC’s Florida Healthy Kids website, and
e. Any other information that may be needed by Enrollees or potential Enrollees. Insurer’s publicly available website is subject to FHKC approval. Insurer shall also provide a non-public website with secure access for Enrollees that shall include:
a. The ability for Enrollees to print a temporary ID card,
b. The ability for Enrollees to request a new ID card, and
c. Enrollee educational materials (unless Insurer chooses to make such materials available on the publicly available website). Insurer’s non-public website is subject to FHKC’s approval.
21.1 Escalated Enrollee Issues FHKC sometimes receives Enrollee complaints or concerns directly from Enrollees or forwarded from state agencies, legislative offices, a...
Enrollee Services. A. 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:
1. Be trained to answer Enrollee inquiries and concerns from Enrollees and prospective Enrollees;
2. Be trained in the use of TTY, Video Relay services, remote interpreting services, how to provide accessible PDF materials, and other Alternative Formats;
3. 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;
4. Inform callers that interpreter services are free;
5. Be knowledgeable about MassHealth, Medicare, and the terms of the Contract, including the Covered Services listed in Appendix A;
6. Be available to Enrollees to discuss and provide assistance with resolving Enrollee Complaints;
7. Have access to the Contractor’s enrollee database, EOHHS’s Eligibility Verification System (EVS), and an electronic provider directory;
8. Make oral interpretation services available free-of-charge to Enrollees in all non-English languages spoken by Enrollees, including American Sign Language (ASL);
9. 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;
10. Demonstrate sensitivity to culture, including disability culture and the Independent Living Philosophy;
11. 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;
12. Provide reasonable accommodations needed to assure effective communication and provide Enrollees with a means to identify their disability to the ICO;
13. 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
14. Ensure that Enrollee Services Representatives make available to Enrollees and Eligible Be...
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:
1. Are Linguistically and Culturally Appropriate, reflecting the diversity of the Contractor’s membership;
2. Are produced in a manner, format, and language that may be easily understood by persons with limited English proficiency;
3. Are translated into Prevalent Languages of the Contractor’s membership;
4. Are made available in Alternative Formats upon request, including video and audio, and information is provided about how to access written materials in those formats and about the availability of auxiliary aids and services;
5. Are mailed with a language card that indicates that the enclosed materials are important and should be translated immediately, and that provides information on how the Enrollee may obtain help with getting the materials translated;
6. Use a font size no smaller than 12 point; and
7. Include a large print tagline (i.e., no smaller than 18 point font size).
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.
ii. A description of the enhanced services that the Contractor offers.
iii. Instructions on how to contact Member or Customer Services of the Contractor and a description of the functions of Member or Customer Services.
iv. Notification that each enrollee is entitled to a copy of his or her medical records and instructions on how to request those records from the Contractor.
v. Instructions on how to utilize the after-hours Medical Advice and Customer Services Department of the Contractor.
vi. A description of the Contractor’s confidentiality policies.
vii. Instructions on how enrolled individuals may acquire services that are covered under Mississippi Medicaid but not under the MississippiCAN.
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:
A. Capture and maintain Contractor enrollment data.
B. Provide information so that the Contractor can send plan materials and information to enrollees.
C. Capture the Primary Care Provider (PCP) names provided by enrollees as well as enrollee health profiles from the State.
D. Be able to receive and transmit NJ Choice assessment system data.
E. Capture and apply Community Residential Services, Assisted Living Services, AFC and Nursing Facility patient payment liability amount to the provider payment amount.
F. Provide Contractor enrollment and Medicaid information to providers.
G. Maintain an enrollee grievance tracking system for Medicaid and NJ FamilyCare enrollees.
H. Produce the required enrollee data reports.
I. Capture and report Member’s living arrangement (HCBS, NF, and hospital). The enrollee module(s) shall interface with all other required modules and permit the access, search, and retrieval of enrollee data by key fields, including date-sensitive information.
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:
2.10.1.1 Be trained to answer Enrollee inquiries and concerns from Enrollees and Prospective Enrollees;
2.10.1.2 Be trained in the use of those services required pursuant to Section 2.9.1.6.3.6.
2.10.1.3 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;
2.10.1.4 Inform callers that interpreter services are free;
2.10.1.5 Be knowledgeable about the Illinois Medicaid program, Medicare, and the terms of the Contract, including the Covered Services listed in Appendix A;
2.10.1.6 Be available to Enrollees to discuss and provide assistance with resolving Enrollee Complaints;
2.10.1.7 Have access to the Contractor’s Enrollee database, the Contractor’s Enrollee handbook, and an electronic Provider and Pharmacy directory;
2.10.1.8 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;
2.10.1.9 Demonstrate sensitivity to culture, including Disability Culture and the independent living philosophy;
2.10.1.10 Provide assistance to Enrollees with cognitive impairments; for example, provide Written Materials in simple, clear language at a reading level of 6.0 and below, and individualized guidance from ESRs to ensure materials are understood;
2.10.1.11 Provide reasonable accommodations needed to assure effective communication and provide Enrollees with a means to identify their disability to the Demonstration Plan;
2.10.1.12 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
2.10.1.13 Ensure that ESRs make available to Enrollees and Potential Enrollees, upon request, information concerning the following:
2.10.1.13.1 The identity, locations, qualifications, and availability of Providers;
2.10.1.13.2 Enrollees’ rights and responsibili...
Enrollee Services. DVHA, through its enrollment subcontractor (currently Maximus), will provide an enrollee helpline function for Global Commitment to Health Demonstration enrollees. DVHA will make available to its enrollment subcontractor an up-to-date provider listing, including names, telephone numbers, office hours, and other relevant information, for use by the helpline operators. DVHA will require each of its IGA partners to identify a liaison to respond to inquiries from the helpline operators and to assist in resolution of enrollee issues.
Enrollee Services. Enrollee Service Representatives (ESRs)
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.
A. Written Materials The Contractor shall unless otherwise provided in this Contract, ensure that all written materials provided by the Contractor to Enrollees:
1. Are Linguistically and Culturally Appropriate, reflecting the diversity of the Contractor’s membership;
2. Are produced in a manner, format, and language that may be easily understood by persons with limited English proficiency;
3. Are translated into Prevalent Languages of the Contractor’s membership;
4. Are made available in Alternative Formats upon request free-of-charge, including video and audio, and information is provided about how to access written materials in those formats and about the availability of auxiliary aids and services, including, at a minimum, services for Enrollees with disabilities;
5. Are mailed with a language card that indicates that the enclosed materials are important and should be translated immediately, and that provides information on how the Enrollee may obtain help with getting the materials translated;
6. Use a font size no smaller than 12 point; and
7. Include a large print tagline (i.e., no smaller than 18 point font size).
B. Requirements for Providing Materials Electronically The Contractor shall not provide Enrollee information required by this Contract electronically unless all of the following are met:
1. The format is readily accessible;
2. The information is placed in a location on the Contractors website that is prominent and readily accessible;
3. The information is provided in an electronic form which can be electronically retained and printed;
4. The information is consistent with the content and language requirements of this Contract; and
5. The Enrollee is informed that the information is available in paper form without charge upon request and the Contractor provides it upon request within 5 business days.
C. Enrollee Information