Medicare Advantage and PDP Program

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Medicare Advantage and PDP Program DEPARTMENT: Medicare Programs Customer Service Version #4 JOB AID TITLE: Star Metrics Job Aid – Reducing CTM Complaints EFFECTIVE DATE: 08/16/2010 PREPARED BY: Tamara Douglas PRODUCT: EGR/PDP MARKET: Medicare Programs REVISION DATE: 11/11/2016

1 of 4 PURPOSE Health Care Reform includes significant changes to the Medicare Advantage program. Several of these key changes include Quality Performance Assessments based on Star Metrics ratings. Star Metrics indicate how successful we are in supporting the needs of our members such as Staying Healthy: Screenings, Tests, and Vaccines, and Managing Chronic (Long-Lasting) Conditions. It also measures our responsiveness and care, member complaints, appeals, the rate at which they choose to leave our health plan, and our telephone Customer Service. Our ratings in these respective measures allow Anthem the opportunity to achieve important financial goals. Our members’ experiences are important and we need to focus on improvements to keep positive experiences for our members at the forefront of what we do. One way we do this is by helping prevent Complaint Tracking Module (CTM) complaints against our plan. CTM complaints are created whenever a member escalates an issue to 1-800 MEDICARE or to CMS. At times, these are issues that can be prevented. This job aid is designed to help you understand how to assist in preventing CTM cases, which will improve the members’ experiences as well as improve Anthem’s Star ratings. You are a critical part of our success. Mkjtyk,3eEvery interaction with our members matters.

PROCEDURE 1. Anytime a provider/member calls 1-800 MEDICARE when they are dissatisfied with Anthem, a complaint is logged and tracked though CTM. Anthem wants to avoid the calls to 1-800 MEDICARE. This has a direct and negative impact on Anthem as a plan. 2. As we continue to build a culture of Customer Advocacy, we must ensure that we perform our work with integrity and that we are advocates on behalf of our customers. It is important that we deliver an exceptional service experience and that our customers can rely on us as a partner in meeting in their health care needs. 3. Reducing or preventing complaints is the responsibility of all associates. Below are some of the areas of high complaints, examples of complaints, and/or ways to avoid. How to Assist in Preventing CTM Cases 1. Common Customer Service issues identified within CTM cases are: A. Inaccurate information provided to the members. DEPARTMENT: Medicare Programs Customer Service Version #4 JOB AID TITLE:

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Star Metrics Job Aid – Reducing CTM Complaints EFFECTIVE DATE: 08/16/2010 2 of 4 B. Customer feels that they were not treated with courtesy and respect C. Plan not providing timely customer service Inaccurate Information Provided to the Members 1. Always refer to the most recent information on Knowledge Library regarding a particular subject to ensure you provide the correct response. 2. If you are not sure of the answer, contact the designated Team Lead/Operations Expert. A. Do not give the provider/member information that you are not certain is the correct response. Customer Feels That They Were Not Treated With Courtesy and Respect 1. Review and be familiar with the Advocacy program and the Advocacy refresher training that is done on an as needed basis. (See Attachments 1 and 2 for information on the Advocacy program).

2. Walk in the member’s shoes. Every interaction with our members matters. 3. Resolve the issue within the plan. Do not refer the member to 1-800-MEDICARE without first getting approval from an OE or Manager. Review and be familiar with plan procedures on how to research and resolve the member’s issue. 4. Reference the following situations in which a beneficiary can be referred to 1-800-MEDICARE, but remember this is not an all inclusive list: A. The beneficiary has a valid election period or SEP and wishes to enroll with a non-Anthem plan B. The beneficiary is claiming marketing misrepresentation concerning an agent with another plan or Medicare itself and needs a CMS SEP to enroll with a different plan 5. Reference the following situations in which a beneficiary can be referred to the Social Security Administration (SSA): A. Part D IRMAA (Income Related Monthly Adjustment Amounts) issues. (Check CS FAQ’s on this topic. The member’s Medicare and You Handbook, also has additional information.) B. The beneficiary was erroneously reported as deceased C. The beneficiary reflects as residing outside of the plan service area due to the beneficiary address is incorrect within SSA records D. The beneficiary was erroneously termed from Medicare A and B

DEPARTMENT: Medicare Programs Customer Service Version #4 JOB AID TITLE: Star Metrics Job Aid – Reducing CTM Complaints EFFECTIVE DATE: 08/16/2010 3 of 4 E. The beneficiary’s date of birth is incorrect in MARx F. The beneficiary has an address change to report to SSA G. Someone is reporting a date of death for a beneficiary Referrals to OEs or Managers 1. The beneficiary is alleging marketing misrepresentation against Anthem and is requesting a CMS SEP to enroll into a different plan. The OE will determine if it is a true marketing misrepresentation. If the OE agrees, the OE will follow the Sales Incident Desk Level Procedure and forward an email to the CTM shared mailbox, Subject: Anthem Marketing Misrepresentation. 2. The beneficiary was erroneously termed from Medicare D and/or the effective date is incorrect. Medicare sets the

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Part D effective date, so if this date needs to be adjusted or reinstated the plan may need to request that update from CMS as an escalated request to the CTM team from the CS OE and/or Manager. Send request to the CTM shared Mailbox, Subject: Update to Part D effective date. - Central PDP includes S5596/MAPD and Eastern email: CMS.Escalated.N4SB@Anthem.com, - Western PDP excludes S5596/MAPD email: PartDCMS@Wellpoint.com 3. The CTM team will email a response within 24 – 48 hours Plan Not Providing Timely Customer Service 1. Route the issue to the appropriate department for resolution and advise the member of the expected timeframe for a response. A. Follow up with intakes/emails sent to other departments. If the CSR has not received a timely response, send a follow up inquiry and include Customer Service management if needed. Tips to Ensure Success in Reducing CTM Complaints 1. Make certain that NO inquiries (i.e. Emails or Intakes) are closed WITHOUT a response back to the department making the inquiry. 2. Understand the importance of the statements made by the associates in each department. Make certain the responses are accurate and CMS or company timeframes are adhered to. When an Anthem representative states that the provider/member will receive a response within a

specified amount of time, follow through with that promise whether or not a resolution has been obtained. 3. Do not advise provider/member to call 1-800-MEDICARE or assist them in calling 1-800-MEDICARE for any items that can be addressed by the plan. DEPARTMENT: Medicare Programs Customer Service Version #4 JOB AID TITLE: Star Metrics Job Aid – Reducing CTM Complaints EFFECTIVE DATE: 08/16/2010 4 of 4 ATTACHMENTS: Attachment 1 – Advocacy Flow Job Aid Attachment 2 – Advocacy Call Flow and Role Model Behaviors

SOURCE(S) / REFERENCE: For assistance with access or system issues in MARx or HPMS please contact the MMA Help Desk: MMA Help Desk Phone: 1-800-927-8069 Email: mapdhelp@cms.hhs.gov Hours of Operation: M-F 6 a.m. to 9 p.m. EST. Original Date: 08/17/2010 Original Author(s): Tamara Douglas- Intake 1468965 Revision Author(s) / Date(s)s: Tamara Douglas 12/14/2011 – 2012 AEP: Updated and added attachments 1&3. Kimmi Durden – 08/27/2013 – CQ WLPRD00491856 – Removed attachment 3 Hot Tips-CTM Reduction Initiative and added its content to job aid. Added new Attachment 3 of Advocacy Role Model Behaviors PPT.

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Kimmi Durden – 11/11/2016 – SP ticket 359 – Updated to change WellPoint to Anthem. Changed Product to EGR/PDP. Updated Attachments with current processes .