The Basics

This standard establishes four requirements for the service that is provided via the customer service toll-free telephone line described in the previous standard.  The services include:

• responses to inquiries about benefit verification and eligibility;
• help with finding providers in your network;
• answers to questions about claims; and
• accepting consumer complaints.

It will be important not only that you are familiar with your organization's policies and procedures regarding how these services are provided, but also the tools used in the provision of those services, such as consumer call logs and any scripts to help with delivering those services.

Management Tips

Make sure your communications plan is explicit on all four requirements of this standard.  The reviewer will reject it on desktop review if it doesn't clearly outline how you address all four issues.  In addition, it is incumbent upon you to provide documentation that you have trained your customer service representatives on how to handle all four types of inquiries.  Finally, while it is not required by the standard, it will help things greatly if you have a comprehensive consumer call log that provide some detail about how each call was handled and resolved.

URAC Accreditation Tips

Two of the elements of this standard are mandatory; the other two are weighted 4.

In addition to the communications plan, on desktop review you should submit customer service representative training records (including agenda and attendance sheets), a sample of your consumer call log, samples of any template correspondents used by the customer services department, and sample telephone statistics.

During the on-site review, the reviewer will both interview and observe customer service representatives taking calls.  During that observation, he/she not only will ask questions of the customer service representative, but also will assess whether the customer service representatives have the appropriate tools to handle all four types of inquiries described in this standard.