Common use of Member Services Helpline and 24 Hour Nurse Line Clause in Contracts

Member Services Helpline and 24 Hour Nurse Line. The Contractor shall maintain a statewide toll-free telephone helpline staffed with trained personnel knowledgeable about the HIP program equipped to handle a variety of member inquiries, including the ability to address member questions, concerns, complaints and requests for PMP changes. The same helpline shall be available to HIP members, so that members may call one number to answer all the family’s questions. Member helpline staff shall be equipped to provide customer service to individuals assigned to the Contractor’s plan who have not yet made their first POWER Account contribution. The helpline staff must be based in Indiana and take at a minimum seventy percent (70%) of the Indiana Medicaid calls, except when emergency rollover is required. The State must be notified if such an emergency is taking place. A minimum of fifty percent (50%) of helpline staff must be employees of the prime Contractor. The Contractor shall staff the member services helpline to provide sufficient “live voice” access to its members during, at a minimum, a twelve (12)-hour business day, from 8 a.m. to 8 p.m. Eastern, Monday through Friday. The call center shall open 60 days prior to the Contractor’s go live date, with State approval. The Contractor shall provide a voice message system that informs callers of the Contractor’s business hours and offers an opportunity to leave a message after business hours. Calls received in the voice message system shall be returned within one (1) business day. The member helpline may be closed on the following holidays: ▪ New Year’s Day; ▪ Xxxxxx Xxxxxx Xxxx, Xx. Day ▪ Memorial Day; ▪ Independence Day (July 4th); ▪ Labor Day; ▪ Thanksgiving; and ▪ Christmas. The Contractor may request that additional days, such as the day after Thanksgiving, be authorized for limited staff attendance. This request shall be submitted to FSSA at least thirty (30) calendar days in advance of the date being requested for limited staff attendance and shall be approved by FSSA. For all days with a closure, early closing or limited staff attendance, members shall have access to the 24-Hour Nurse Call Line as appropriate. Call center closures, limited staffing or early closures shall not burden a member’s access to care. The member services helpline shall offer language translation services for members whose primary language is not English and shall offer automated telephone menu options in English and Spanish. A member services messaging option shall be available after business hours in English and Spanish. The Contractor shall provide Telecommunications Device for the Deaf (TDD) services for hearing impaired members. There must also be at least 1 fluent Burmese speaker and 1 fluent Spanish speaker physically present (i.e., not via a language translation line) to answer member calls during all “live” operating hours. Member services helpline staff shall be trained in the HIP program to ensure that member questions and concerns are resolved as expeditiously as possible. The Contractor shall have the ability to warm transfer members to outside entities including the Enrollment Broker, the Division of Family Resources (DFR) and provider offices. Additionally, the Contractor shall ensure the warm transfer of calls for members that require attention from a Contractor care manager. The Contractor shall ensure the care manager has access to all information necessary to resolve the member’s issues. Any messages left with care managers must be returned by the next business day. The Contractor shall maintain a system for tracking and reporting the number and type of members’ calls and inquiries it receives during business hours and non- business hours. The Contractor shall monitor its member services helpline service and report its telephone service level performance to FSSA in the timeframes and specifications described in the HIP MCE Reporting Manuals. The Contractor’s member services helpline staff shall be prepared to efficiently respond to member concerns or issues including, but not limited to the following: ▪ Access to health care services; ▪ Identification or explanation of covered services; ▪ Special health care needs; ▪ Procedures for submitting a member grievance or appeal; ▪ Potential fraud or abuse; ▪ Changing PMPs; ▪ POWER Accounts and POWER Account balances; ▪ HIP POWER Account contributions, including initial fast track prepayments; ▪ Transfers between HIP benefit plans; ▪ Incentive programs; ▪ Disease management services, care management and complex case management services; ▪ Recommended age and sex appropriate preventive services (HIP only); ▪ Transfers between Hoosier Healthwise and HIP coverage; ▪ Employer and other third-party HIP POWER Account contributions; ▪ Balance billing issues; ▪ Referrals to local services or community-based organizations for assistance; and ▪ Health crises, including but not limited to suicidal callers. Upon a member’s enrollment with the Contractor, the Contractor shall inform the member about the member services helpline. The Contractor should encourage its members to call the member services helpline as the first resource for answers to questions or concerns about HIP, PMP issues, benefits, Contractor policies, etc. The Contractor shall maintain sufficient equipment and staff to ensure the following: ▪ For any calendar month, at least ninety-seven percent (97%) of all phone calls to the helpline must reach the call center menu within thirty (30) seconds. ▪ For any calendar month, at least eighty-five percent (85%) of all phone calls to an approved automated helpline must be answered by a helpline representative within thirty (30) seconds after the call has been routed through the call center menu. Answered means that the call is picked up by a qualified helpline staff person.

Member Services Helpline and 24 Hour Nurse Line. The Contractor shall maintain a statewide toll-free telephone helpline staffed with trained personnel knowledgeable about the HIP Hoosier Healthwise program equipped to handle a variety of member inquiries, including the ability to address member questions, concerns, complaints and requests for PMP changes. The same helpline shall be available to HIP Hoosier Healthwise members, so that members may call one number to answer all the family’s questions. Member helpline staff shall be equipped to provide customer service to individuals assigned to the Contractor’s plan who have not yet made their first POWER Account contribution. The helpline staff must be based in Indiana and take at a minimum seventy percent (70%) of the Indiana Medicaid calls, except when emergency rollover is required. The State must be notified if such an emergency is taking place. A minimum of fifty percent (50%) of helpline staff must be employees of the prime Contractor. The Contractor shall staff the member services helpline to provide sufficient “live voice” access to its members during, at a minimum, a twelve (12)-hour business day, from 8 a.m. to 8 p.m. Eastern, Monday through Friday. The call center shall open 60 days prior to the Contractor’s go live date, with State approval. The Contractor shall provide a voice message system that informs callers of the Contractor’s business hours and offers an opportunity to leave a message after business hours. Calls received in the voice message system shall be returned within one (1) business day. The member helpline may be closed on the following holidays: ▪ New Year’s Day; ▪ Xxxxxx Xxxxxx Xxxx, Xx. Day ▪ Memorial Day; ▪ Independence Day (July 4th); ▪ Labor Day; ▪ Thanksgiving; and ▪ Christmas. The Contractor may request that additional days, such as the day after Thanksgiving, be authorized for limited staff attendance. This request shall must be submitted to FSSA at least thirty (30) calendar days in advance of the date being requested for limited staff attendance and shall must be approved by FSSA. For all days with a closure, early closing or limited staff attendance, members shall have access to the 24-Hour Nurse Call Line as appropriate. Call center closures, limited staffing or early closures shall not burden a member’s access to care. The member services helpline shall offer language translation services for members whose primary language is not English and shall offer automated telephone menu options in English and Spanish. A member services messaging option shall be available after business hours in English and Spanish. The Contractor shall provide Telecommunications Device for the Deaf (TDD) services for hearing impaired members. There must also be at least 1 fluent Burmese speaker and 1 fluent Spanish speaker physically present (i.e., not via a language translation line) to answer member calls during all “live” operating hours. Member services helpline staff shall be trained in the HIP Hoosier Healthwise program to ensure that member questions and concerns are resolved as expeditiously as possible. The Contractor shall have the ability to warm transfer members to outside entities including the Enrollment Broker, the Division of Family Resources (DFR) and provider offices. Additionally, the Contractor shall ensure the warm transfer of calls for members that require attention from a Contractor care manager. The Contractor shall ensure the care manager has access to all information necessary to resolve the member’s issues. Any messages left with care managers must be returned by the next business day. The Contractor shall maintain a system for tracking and reporting the number and type of members’ calls and inquiries it receives during business hours and non- business hours. The Contractor shall monitor its member services helpline service and report its telephone service level performance to FSSA in the timeframes and specifications described in the HIP Hoosier Healthwise MCE Reporting ManualsManual. The Contractor’s member services helpline staff shall be prepared to efficiently respond to member concerns or issues including, but not limited to the following: ▪ Access to health care services; ▪ Identification or explanation of covered services; ▪ Special health care needs; ▪ Procedures for submitting a member grievance or appeal; ▪ Potential fraud or abuse; ▪ Changing PMPs; ▪ POWER Accounts and POWER Account balances; Premium payment requirements (for Package C only) ▪ HIP POWER Account contributions, including initial fast track prepayments; ▪ Transfers between HIP benefit plans; Required copays (for Package C only) ▪ Incentive programs; ▪ Disease management services, care management and complex case management services; ▪ Recommended age and sex appropriate preventive services (HIP only); ▪ Transfers between Hoosier Healthwise and HIP coverage; ▪ Employer and other third-party HIP POWER Account contributions; ▪ Balance billing issues; ▪ Referrals to local services or community-based organizations for assistance; and ▪ Health crises, including but not limited to suicidal callers. Upon a member’s enrollment with the Contractor, the Contractor shall inform the member about the member services helpline. The Contractor should encourage its members to call the member services helpline as the first resource for answers to questions or concerns about HIPHoosier Healthwise, PMP issues, benefits, Contractor policies, etc. The Contractor shall maintain sufficient equipment and staff to ensure the following: ▪ For any calendar month, at least ninety-seven percent (97%) of all phone calls to the helpline must reach the call center menu within thirty (30) seconds. ▪ For any calendar month, at least eighty-five percent (85%) of all phone calls to an approved automated helpline must be answered by a helpline representative within thirty (30) seconds after the call has been routed through the call center menu. Answered means that the call is picked up by a qualified helpline staff person. ▪ For any calendar month, at least ninety-five percent (95%) of all phone calls to an approved automated helpline must be answered by a helpline representative within sixty (60) seconds after the call has been routed through the call center menu. Answered means that the call is picked up by a qualified helpline staff person. ▪ If the Contractor does not maintain an approved automated call distribution system, for any calendar month, at least ninety-five percent (95%) of all phone calls to the helpline must be answered within thirty (30) seconds. ▪ Hold time does not exceed one (1) minute in any instance, or thirty (30) seconds, on average. ▪ For any calendar month, the lost call (abandonment rate) associated with the helpline does not exceed five percent (5%). The Contractor shall provide a backup solution for phone service in the event of a power failure or outage or other interruption in service. Such plan shall include, at minimum, the following: ▪ A notification plan that ensures FSSA is notified when the Contractor's phone system is inoperative, or a back-up system is being utilized; and ▪ Manual back-up procedure to allow requests to continue being processed if the system is down. In addition to the member services helpline, which is staffed during regular business hours, the Contractor shall operate a toll-free twenty-four (24) hour nurse call line. The Contractor shall provide nurse triage telephone services for members to receive medical advice twenty-four (24) hours-a-day/seven (7)-days-a-week from trained medical professionals. The twenty-four (24) hour nurse call line should be well publicized and designed as a resource to members to help discourage inappropriate Emergency room use. The twenty-four (24) hour nurse call line must have a system in place to communicate all issues with the member’s providers. In addition, as set forth in Section 3.9, the 24-Hour Nurse Call Line must be equipped to provide advice for Hoosier Healthwise members seeking services from hospital Emergency departments.

Member Services Helpline and 24 Hour Nurse Line. The Contractor shall maintain a statewide toll-free telephone helpline staffed with trained personnel knowledgeable about the HIP program equipped to handle a variety of member inquiries, including the ability to address member questions, concerns, complaints and requests for PMP changes. The same helpline shall be available to HIP members, so that members may call one number to answer all the family’s questions. Member helpline staff shall be equipped to provide customer service to individuals assigned to the Contractor’s plan who have not yet made their first POWER Account contribution. The helpline staff must be based in Indiana and take at a minimum seventy percent (70%) of the Indiana Medicaid calls, except when emergency rollover is required. The State must be notified if such an emergency is taking place. A minimum of fifty percent (50%) of helpline staff must be employees of the prime Contractor. The Contractor shall staff the member services helpline to provide sufficient “live voice” access to its members during, at a minimum, a twelve (12)-hour business day, from 8 a.m. to 8 p.m. Eastern, Monday through Friday. The call center shall open 60 days prior to the Contractor’s go live date, with State approval. The Contractor shall provide a voice message system that informs callers of the Contractor’s business hours and offers an opportunity to leave a message after business hours. Calls received in the voice message system shall be returned within one (1) business day. The member helpline may be closed on the following holidays: ▪ New Year’s Day; ▪ Xxxxxx Xxxxxx Xxxx, Xx. Day ▪ Memorial Day; ▪ Independence Day (July 4th); ▪ Labor Day; ▪ Thanksgiving; and ▪ Christmas. The Contractor may request that additional days, such as the day after Thanksgiving, be authorized for limited staff attendance. This request shall be submitted to FSSA at least thirty (30) calendar days in advance of the date being requested for limited staff attendance and shall be approved by FSSA. For all days with a closure, early closing or limited staff attendance, members shall have access to the 24-Hour Nurse Call Line as appropriate. Call center closures, limited staffing or early closures shall not burden a member’s access to care. The member services helpline shall offer language translation services for members whose primary language is not English and shall offer automated telephone menu options in English and Spanish. A member services messaging option shall be available after business hours in English and Spanish. The Contractor shall provide Telecommunications Device for the Deaf (TDD) services for hearing impaired members. There must also be at least 1 fluent Burmese speaker and 1 fluent Spanish speaker physically present (i.e., not via a language translation line) to answer member calls during all “live” operating hours. Member services helpline staff shall be trained in the HIP program to ensure that member questions and concerns are resolved as expeditiously as possible. The Contractor shall have the ability to warm transfer members to outside entities including the Enrollment Broker, the Division of Family Resources (DFR) and provider offices. Additionally, the Contractor shall ensure the warm transfer of calls for members that require attention from a Contractor care manager. The Contractor shall ensure the care manager has access to all information necessary to resolve the member’s issues. Any messages left with care managers must mus t be returned by the next business day. The Contractor shall maintain a system for tracking and reporting the number and type of members’ calls and inquiries it receives during business hours and non- business hours. The Contractor shall monitor its member services helpline service and report its telephone service level performance to FSSA in the timeframes and specifications described in the HIP MCE Reporting Manuals. The Contractor’s member services helpline staff shall be prepared to efficiently respond to member concerns or issues including, but not limited to the following: ▪ Access to health care services; ▪ Identification or explanation of covered services; ▪ Special health care needs; ▪ Procedures for submitting a member grievance or appeal; ▪ Potential fraud or abuse; ▪ Changing PMPs; ▪ POWER Accounts and POWER Account balances; ▪ HIP POWER Account contributions, including initial fast track prepayments; ▪ Transfers between HIP benefit plans; ▪ Incentive programs; ▪ Disease management services, care management and complex case management services; ▪ Recommended age and sex appropriate preventive services (HIP only); ▪ Transfers between Hoosier Healthwise and HIP coverage; ▪ Employer and other third-party HIP POWER Account contributions; ▪ Balance billing issues; ▪ Referrals to local services or community-based organizations for assistance; and ▪ Health crises, including but not limited to suicidal callers. Upon a member’s enrollment with the Contractor, the Contractor shall inform the member about the member services helpline. The Contractor should encourage its members to call the member services helpline as the first resource for answers to questions or concerns about HIP, PMP issues, benefits, Contractor policies, etc. The Contractor shall maintain sufficient equipment and staff to ensure the following: ▪ For any calendar month, at least ninety-seven percent (97%) of all phone calls to the helpline must reach the call center menu within thirty (30) seconds. ▪ For any calendar month, at least eighty-five percent (85%) of all phone calls to an approved automated helpline must be answered by a helpline representative within thirty (30) seconds after the call has been routed through the call center menu. Answered means that the call is picked up by a qualified helpline staff person.

Member Services Helpline and 24 Hour Nurse Line. The Contractor shall maintain a statewide dedicated toll-free telephone member services helpline staffed with trained personnel knowledgeable about the HIP program Hoosier Care Connect program. Helpline staff shall be equipped to handle a variety of member inquiries, including the ability to address member questions, concerns, complaints and requests for PMP changes. The same member services helpline shall be available to HIP members, so that members may call one number to answer all the family’s questions. Member helpline staff shall be equipped to provide customer service to individuals assigned to the Contractor’s plan who have not yet made their first POWER Account contribution. The helpline staff must be based in Indiana staffed and take at a minimum seventy percent (70%) of the Indiana Medicaid calls, except when emergency rollover is required. The State must be notified if such an emergency is taking place. A minimum of fifty percent (50%) of helpline staff must be employees of the prime Contractor. The Contractor shall staff the member services helpline to provide sufficient “accessible via live voice” access to its members duringvoice coverage, at a minimum, a EXHIBIT 1.M SCOPE OF WORK minimum for twelve (12)-hour business 12) hours per day, Monday through Friday, from 8 a.m. to 8 p.m. EasternEastern Standard Time. Beginning one (1) year after the Contract effective date, Monday through Friday. The the Contractor may request FSSA approval to modify the hours of operation of the member services helpline based on call center shall open 60 days prior to the Contractor’s go live date, with State approvaltraffic data. FSSA retains sole discretion for approval or denial of such requests. The Contractor shall provide a voice message system that informs callers of the Contractor’s business hours and offers an opportunity to leave a message after business hours. Calls received in the voice message system shall be returned within one (1) the following business day. The member services helpline may be closed on the following holidays: ▪  New Year’s Day; ▪  Xxxxxx Xxxxxx Xxxx, Xx. Day ▪ Day;  Memorial Day; ▪  Independence Day (July 4th); ▪  Labor Day; ▪  Thanksgiving; and ▪  Christmas. The Contractor may request that additional days, such as the day after Thanksgiving, be authorized for limited staff attendance. This request shall be submitted to FSSA at least thirty (30) calendar days in advance of the date being requested for limited staff attendance and shall be approved by FSSA. For all days with a closure, early closing or limited staff attendance, members shall must have access to the twenty-four (24-Hour Nurse Call Line as appropriate) hour nurse call line described below. Call center closures, limited staffing or early closures shall not burden a member’s access to care. The member services helpline shall offer language translation services for members whose primary language is not English and shall offer automated telephone menu options in English and Spanish. A member services messaging option shall be available after business hours in English and Spanish. The Contractor shall provide Telecommunications Device for the Deaf (TDD) services for hearing impaired members. There Respondents shall also describe any additional technology to be leveraged to communicate with hearing impaired members. Additionally, the member services helpline must also be at least 1 fluent Burmese speaker and 1 fluent Spanish speaker physically present (i.e., not via a offer language translation line) to answer member calls during all “live” operating hoursservices for members whose primary language is not English. Member services helpline staff shall Automated telephone menu options must be trained made available in the HIP program to ensure that member questions English and concerns are resolved as expeditiously as possibleSpanish. The Contractor shall must have the ability to warm transfer members to outside entities including the Enrollment Broker, the Division of Family Resources (DFR) DFR and provider offices. Additionally, the Contractor shall ensure the warm transfer of calls for members that require attention from a Contractor care manager. The Contractor shall ensure the care manager has access to all information necessary to resolve the member’s issues. Any messages left with care managers must be returned by the next business day. The Contractor shall must maintain a system for tracking and reporting the number and type of members’ member calls and inquiries it receives during business hours and non- non-business hours. The Contractor shall must monitor its member services helpline service and report its telephone service level performance to FSSA in the timeframes and specifications described in the HIP MCE Hoosier Care Connect Reporting ManualsManual, which shall be provided to Contractor following the Contract award date. The Contractor’s member services helpline staff shall must be prepared to efficiently respond to member concerns or issues including, but not limited to the following: ▪  Access to health care services; ▪ ; EXHIBIT 1. M SCOPE OF WORK  Identification or explanation of covered services; ▪  Special health care needs; ▪  Procedures for submitting a member grievance or appeal; ▪  Potential fraud or abuse; ▪  Changing PMPs, if the Contractor utilizes a PMP model; ▪ POWER Accounts and POWER Account balances; ▪ HIP POWER Account contributions, including initial fast track prepayments; ▪ Transfers between HIP benefit plans; ▪  Incentive programs; ▪  Disease management servicesmanagement, care management and complex case management services; ▪ Recommended age and sex appropriate preventive services (HIP only); ▪ Transfers between Hoosier Healthwise and HIP coverage; ▪ Employer and other third-party HIP POWER Account contributions; ▪ Balance billing issues; ▪ Referrals to local services or community-based organizations for assistance; and ▪  Health crises, including but not limited to to, suicidal callers. Upon a member’s enrollment with the Contractor, the Contractor shall inform the member about the member services helpline. The Contractor should encourage its members to call the member services helpline as the first resource for answers to questions or concerns about HIP, PMP ; and  Balance billing issues, benefits, Contractor policies, etc. The Contractor shall maintain sufficient equipment and staff to ensure the following: ▪  For any calendar month, at least ninety-seven percent (97%) of all phone calls to the helpline must reach the call center menu within thirty (30) seconds. ▪  For any calendar month, at least eighty-five percent (85%) of all phone calls to an approved automated helpline must be answered by a helpline representative within thirty (30) seconds after the call has been routed through the call center menu. Answered means that the call is picked up by a qualified helpline staff person.  For any calendar month, at least ninety-five percent (95%) of all phone calls to an approved automated helpline must be answered by a helpline representative within sixty (60) seconds after the call has been routed through the call center menu. Answered means that the call is picked up by a qualified helpline staff person.  If the Contractor does not maintain an approved automated call distribution system, for any calendar month, at least ninety-five percent (95%) of all phone calls to the helpline must be answered within thirty (30) seconds.  Hold time does not exceed one (1) minute in any instance, or thirty (30) seconds, on average.  For any calendar month, the lost call (abandonment rate) associated with the helpline does not exceed five percent (5%). Respondents shall provide a description of the proposed backup solution for phone service in the event of a power failure or outage or other interruption in service. Such plan shall include, at minimum, the following:  A notification plan that ensures FSSA is notified when the Contractor's phone system is inoperative or a back-up system is being utilized; and  Manual back-up procedure to allow requests to continue being processed if the system is down. In addition to the member services helpline which is staffed during regular business hours, the Contractor shall operate a toll-free twenty-four (24) hour nurse call line. The EXHIBIT 1. M SCOPE OF WORK Contractor shall provide nurse triage telephone services for members to receive medical advice twenty-four (24) hours-a-day/seven (7)-days-a-week from trained medical professionals. The twenty-four (24) hour nurse call line should be well publicized and designed as a resource to members to help discourage inappropriate emergency room use. The twenty-four (24) hour nurse call line must have a system in place to communicate all issues with the member’s providers. In addition, as set forth in Section 3.3.1, the 24-Hour Nurse Call Line must be equipped to provide advice and copayment waivers for Hoosier Care Connect members seeking services from hospital emergency departments.