Claims Workflow

Please note this form should only be submitted in the event the call is regarding a CLAIM ONLY.

DO NOT complete this form for anything related to billing, refunds, denial of enrollment, or other service-related activities as it will create a delay for the caller.

<<Please be sure to address all coverages before you end the call.>>

Vendor Quality Control Tool

- Contact Center*
- Agent Username*
- Agent Type*
- Call record ID (leave blank if live monitoring)
- Date of call*
  MM slash DD slash YYYY
- Coverage ID
- Cancellation Rebuttal Procedures Not Followed*
  - PROCEDURES FOLLOWED
  - Did not obtain reason for cancellation
  - Did not read or offer a rebuttal
  - Read wrong rebuttal
  - Read rebuttal too fast
  - Did not read verbatim - Keep coverage until end of billing period
  - Picked wrong cancellation or save reason code
- Other cancellation procedures not followed
- Procedures*
- Other procedures not followed
- Soft skills*
- Customer / Caller Satisfied*
- First Call Resolution / Issue Resolved*
- Great / Gold Call*
- Coaching feedback

Beneficiary change / confirmation
Call disposition / reason
Call opening
Cancel policy
Comment record
Coverage not accessed
Email option not offered
Escalate to ExRT
Escalation not necessary
Inaccurate information provided
Initiate claim
Issue refund
Product knowledge
Provide accurate billing information
Read cancel rebuttal
Read comment screen (previous comments)
Read customer policy summary
Read exclusions script verbatim
Send appropriate letter / form
Send duplicate certificate
Send proof of enrollment
Status of claim
Transfer to Tier II
Verification
PROCEDURES FOLLOWED