Common use of Member Services Call Center Clause in Contracts

Member Services Call Center. The CONTRACTOR shall operate a call center with a toll-free telephone line (Member services information line) to respond to Member questions, concerns, inquiries, and complaints from the Member, Representative or the Member’s Provider. The call center and its staff must be located and operated in the State of New Mexico. With prior written approval from HCA, the CONTRACTOR may locate specially-trained call center staff in other locations outside New Mexico so long as calls can be transferred with a Warm Transfer during the hours delineated in Sections 4.16.1.6 and 4.16.1.9 of this Agreement. With prior written approval from HCA. The CONTRACTOR may also allow Major Subcontractors that are providing Covered Services to Members to operate a call center specific to those Covered Services being provided. The CONTRACTOR shall develop Member services information line policies and procedures that address staffing, training, hours of operation, access, and response standards, transfers/referrals, including referrals from all sources, monitoring of calls via recording or other means, translation/interpretation, and compliance with standards. The CONTRACTOR’s call center shall have the capacity for HCA or its agent to monitor calls remotely. The Member services information line shall be equipped to handle calls from callers with LEP, as well as calls from Members who are hearing impaired. The CONTRACTOR shall have bilingual representatives based on the threshold of a prevalent non-English language specified in Section 4.15.2.5 of this Agreement. The CONTRACTOR shall ensure that the Member services information line is staffed adequately to respond to Members’ questions and meet -specified call center metrics at a minimum, from 8 a.m. to 5 p.m., Mountain Time, Monday through Friday, except for New Year’s Day, Memorial Day, Juneteenth, Independence Day, Labor Day, Thanksgiving Day, and Christmas Day on the actual day on which the holiday falls. The call center staff shall be trained to respond to Member questions in all areas, including but not limited to Covered Services, including the ABP, the Provider network, and Member enrollment issues. The call center staff shall receive ongoing training, at least quarterly, through instructor-led trainings and staff meetings. The call center staff must receive training immediately following changes to service delivery and Covered Services. The Member services information line shall be staffed twenty-four (24) hours a day, seven (7) days a week with qualified nurses to triage urgent care and emergency calls from Members and to facilitate transfer of calls to a care coordinator. The CONTRACTOR may meet this requirement by having a separate nurse triage/nurse advice line that otherwise meets all of the requirements of this Section 4.16.1. Staff providing triage/nurse advice services must be registered nurses, physician assistants, nurse practitioners, or medical doctors. At all times there must be staff on hand equipped to handle Behavioral Health crises. The primary intent of this triage is to decrease inappropriate utilization of emergency rooms and improve coordination and continuity of care with a Member’s PCP. However, having the phone line staffed by someone who is also able to provide treatment as appropriate is encouraged. The CONTRACTOR shall ensure that all calls from Members to the nurse triage/nurse advice line that require immediate attention are immediately addressed by qualified nurses or transferred to a care coordinator, whichever is most appropriate. During normal business hours, the transfer to the Care Coordination unit shall be a Warm Transfer. After normal business hours, if the CONTRACTOR cannot transfer the call to the Care Coordination unit as a Warm Transfer, the CONTRACTOR shall ensure that a care coordinator is notified about the call and returns the Member’s call within thirty (30) minutes. When returning the call the care coordinator must have access to the necessary information (e.g., the Member’s CCP) to resolve Member issues. The CONTRACTOR shall implement protocols, with prior written approval from HCA, that describe how calls to the nurse triage/nurse advice line from Members will be handled. The CONTRACTOR shall implement protocols, with prior written approval from HCA, to ensure that calls to the Member services information line that should be transferred/referred to other CONTRACTOR staff, including but not limited to, a Member services supervisor or a care coordinator, or to an external entity, are transferred/referred appropriately. The CONTRACTOR shall measure and monitor the accuracy of responses and phone etiquette and take corrective action, as necessary, to ensure the accuracy of responses and appropriate phone etiquette by staff. The CONTRACTOR shall have an automated system available during non-business hours, including weekends and holidays. This automated system shall provide callers with operating instructions on what to do in case of an emergency, the option to speak directly to a nurse, and shall include, at a minimum, a voice mailbox for callers to leave messages. The CONTRACTOR shall ensure that the voice mailbox has adequate capacity to receive all messages. The CONTRACTOR shall return all messages by the next Business Day. The call center staff shall have access to electronic documentation from previous calls made by, or on behalf of, the Member to the Member services information line, nurse triage/nurse advice line, and the Care Coordination department. Performance Standards for Member Services Line/Queue The CONTRACTOR shall adequately staff the Member services information line to ensure that the Member line and the nurse triage/nurse advice line or queue, meet the following performance standards independently on a monthly basis: less than five percent (5%) call abandonment rate; ninety percent (90%) of calls are answered by a live voice within thirty (30) seconds; average wait time for assistance does not exceed thirty (30) seconds; seventy percent (70%) of all calls are resolved during the first call; and one hundred percent (100%) of voicemails returned by next Business Day. The CONTRACTOR’s call center systems shall have the capability to track call center metrics as identified above. Metrics shall be reported separately for the Member services information line and the nurse triage/nurse advice line/queue.

Member Services Call Center. The CONTRACTOR shall operate a call center with a toll-free telephone line (Member services information line) to respond to Member questions, concerns, inquiries, and complaints from the Member, Representative or the Member’s Provider. The call center and its staff must be located and operated in the State of New Mexico. With prior written approval from HCAHSD, the CONTRACTOR may locate specially-trained call center staff in other locations outside New Mexico so long as calls can be transferred with a Warm Transfer during the hours delineated in Sections 4.16.1.6 and 4.16.1.9 of this Agreement. With prior written approval from HCA. The HSD, the CONTRACTOR may also allow Major Subcontractors that are providing Covered Services to Members to operate a call center specific to those Covered Services being provided. The CONTRACTOR shall develop Member services information line policies and procedures that address staffing, training, hours of operation, access, and response standards, transfers/referrals, including referrals from all sources, monitoring of calls via recording or other means, translation/interpretation, and compliance with standards. The CONTRACTOR’s call center shall have the capacity for HCA HSD or its agent to monitor calls remotely. The Member services information line shall be equipped to handle calls from callers with LEP, as well as calls from Members who are hearing impaired. The CONTRACTOR shall have bilingual representatives based on the threshold of a prevalent non-English language specified in Section 4.15.2.5 of this Agreement. The CONTRACTOR shall ensure that the Member services information line is staffed adequately to respond to Members’ questions and meet -specified call center metrics at a minimum, from 8 a.m. to 5 p.m., Mountain Time, Monday through Friday, except for New Year’s Day, Memorial Day, Juneteenth, Independence Day, Labor Day, Thanksgiving Day, and Christmas Day on the actual day on which the holiday falls. The call center staff shall be trained to respond to Member questions in all areas, including but not limited to Covered Services, including the ABP, the Provider network, and Member enrollment issues. The call center staff shall receive ongoing training, at least quarterly, through instructor-led trainings and staff meetings. The call center staff must receive training immediately following changes to service delivery and Covered Services. The Member services information line shall be staffed twenty-four (24) hours a day, seven (7) days a week with qualified nurses to triage urgent care and emergency calls from Members and to facilitate transfer of calls to a care coordinator. The CONTRACTOR may meet this requirement by having a separate nurse triage/nurse advice line that otherwise meets all of the requirements of this Section 4.16.1. Staff providing triage/nurse advice services must be registered nurses, physician assistants, nurse practitioners, or medical doctors. At all times there must be staff on hand equipped to handle Behavioral Health crises. The primary intent of this triage is to decrease inappropriate utilization of emergency rooms and improve coordination and continuity of care with a Member’s PCP. However, having the phone line staffed by someone who is also able to provide treatment as appropriate is encouraged. The CONTRACTOR shall ensure that all calls from Members to the nurse triage/nurse advice line that require immediate attention are immediately addressed by qualified nurses or transferred to a care coordinator, whichever is most appropriate. During normal business hours, the transfer to the Care Coordination unit shall be a Warm Transfer. After normal business hours, if the CONTRACTOR cannot transfer the call to the Care Coordination unit as a Warm Transfer, the CONTRACTOR shall ensure that a care coordinator is notified about the call and returns the Member’s call within thirty (30) minutes. When returning the call the care coordinator must have access to the necessary information (e.g., the Member’s CCP) to resolve Member issues. The CONTRACTOR shall implement protocols, with prior written approval from HCAHSD, that describe how calls to the nurse triage/nurse advice line from Members will be handled. The CONTRACTOR shall implement protocols, with prior written approval from HCAHSD, to ensure that calls to the Member services information line that should be transferred/referred to other CONTRACTOR staff, including but not limited to, a Member services supervisor or a care coordinator, or to an external entity, are transferred/referred appropriately. The CONTRACTOR shall measure and monitor the accuracy of responses and phone etiquette and take corrective action, as necessary, to ensure the accuracy of responses and appropriate phone etiquette by staff. The CONTRACTOR shall have an automated system available during non-business hours, including weekends and holidays. This automated system shall provide callers with operating instructions on what to do in case of an emergency, the option to speak directly to a nurse, and shall include, at a minimum, a voice mailbox for callers to leave messages. The CONTRACTOR shall ensure that the voice mailbox has adequate capacity to receive all messages. The CONTRACTOR shall return all messages by the next Business Day. The call center staff shall have access to electronic documentation from previous calls made by, or on behalf of, the Member to the Member services information line, nurse triage/nurse advice line, and the Care Coordination department. Performance Standards for Member Services Line/Queue The CONTRACTOR shall adequately staff the Member services information line to ensure that the Member line and the nurse triage/nurse advice line or queue, meet the following performance standards independently on a monthly basis: less than five percent (5%) call abandonment rate; ninety percent (90%) of calls are answered by a live voice within thirty (30) seconds; average wait time for assistance does not exceed thirty (30) seconds; seventy percent (70%) of all calls are resolved during the first call; and one hundred percent (100%) of voicemails returned by next Business Day. The CONTRACTOR’s call center systems shall have the capability to track call center metrics as identified above. Metrics shall be reported separately for the Member services information line and the nurse triage/nurse advice line/queue.