Points Points

2020 Centene Enterprise Call Quality Form Earned Possible

Compliance
C.1 - Adheres to all HIPAA and PHI guidelines (old form C0, C1) (LW - Compliance -HIPAA y 30 30
verification)
1. Releases PHI or PII without caller verification
2. Releases PHI or PII to unauthorized individual
3. Refuses to release PHI or PII to beneficiary, consumer or authorized individual

4. Incorrectly verifies caller and member that could result in an unauthorized individual receiving PHI or PII
5. Does not follow disclosure rules when receiving a transferred call

Y 10 10
C.2 - Provides all required disclaimer/education text language (LC - C.3) (LW - Process)
• Does not read OMNI/CareConnects disclaimers and educational texts

Y 10 10
C.3 - Provides accurate information pertaining to plan program and policies (LC - old form
LC - C2) (LW - Accurate & Complete Info; Barriers Identification - Appropriate Tools)
• Provides or confirms inaccurate information to inlcude EOC/SOB/Plan Website information (outside of
Omni)
• Provides an incorrect timeframe (outside of Omni)

C.4 - Resolves caller inquiry to the extent possible (LC - old form C2, C4) (LW - Appeals & Y 15 15
Grievances; Interpreter Services)

•Does not adhere to established work processes (including those for Grievance, Appeal, Quality of Care,
Access to Care, Organization determination, Coverage determination, and Language Services).
• Does not correctly assess the reason for the call
• Does not transfer the call when needed
• Does not provide referral needed to resolve issue
• Does not submit an escalation when needed to resolve issue
• Submits an incorrect escalation
• Does not address any implied requests (medical emergency or financial hardship)
• Does not perform/perform all necessary actions and steps to resolve the caller's inquiry as outlined in
scripting or approved materials

C.5 - Adheres to critical business processes (LC - old form C7, C8, C9) (LW - Y 10 10
Documentation; Process & Accuracy - Accurate Documentation)
• Does not log scripts or approved materials read or used to assist the caller
• Does not log referrals provided
N/A scoring:
a. Does not accurately select radio buttons in OMNI/CareConnects
• Does not open a call or contact record in OMNI/CareConnects
• Does not close the call or contact record in OMNI/CareConnects
• Opens a call or contact record incorrectly in OMNI/CareConnects
• Does not update the caller’s name or relationship to the caller in OMNI/CareConnects
• Does not enter notes for a transferred call
• Transfers unnecessarily or incorrectly
• Does not enter notes or information as required for an escalation
• Does not document research or provide basic summary of what transpired on the call
• Does not follow other procedures or special direction for the plan
• Does not fully document call
• Does not route to the appropriate workbasket (Omni) or the appropriate action code was not used
(CareConnects)

C.6 - Adhered to any State specific requirements (LC - old form C5) Y 10 10

C.7 - Interaction Handling (LC - old form C6, C10) (LW - Appropriate Behavior) Y 15 15
• Incorrectly handled an emergency or crisis call
• Display of call avoidance, intentional disconnection, or failure to ensure the call has ended
appropriately (define in guidelines)
• Makes disparaging remarks about program or policies (define in guidelines) "Member abrasion" instead of components 3 & 4
• Spoke in a condescending/rude manner (define in guidelines)

Points
%(Score) Earned Points Earned

100.00% 100 100

Service Skills (pass/fail section - must pass 3 of 4 sections)
SK.1 - Greeting (LW - Engagement) 4 of 5 = Pass
1.0 Answered within 3 seconds, branded call and provided name in the greeting Y N/A N/A
1.1 Included an offer of assistance in greeting ("How can I help you today?") Y N/A N/A
1.2 Verbally acknowledged the caller's issue ("I'd be happy to help you with that", etc.) Y N/A N/A
1.3 Asked member if any contact information has changed recently (as appropriate for Legacy Wellcare) Y N/A N/A
1.4 Asked if member has any other health insurance/Asked if provider is aware if member has other
insurance (Provider Calls)
1.5 Verified and updated PCP (Personal Doctor) Y N/A N/A
1.6 Addressed any relevant Care Gaps / Provided Timely Filing guidelines when appropriate (Provider
Calls)
Did more than one component receive a "No" response? Y N/A N/A
SK.2 - Communication Skills (LW - Improved Demeanor; Effective Communication; Engagement;
Efficiencies) 4 of 5 = Pass
2.0 Empathized with the caller when appropriate Y N/A N/A
2.1 Developed a rapport with the caller (used the caller's name, etc.) Y N/A N/A
2.2 Demonstrated courtesy and respect Y N/A N/A
2.3 Demonstrated active listening Y N/A N/A
2.4 Provided information in a confident, clear, and efficient manner (define in guidelines) Y N/A N/A
Did more than one component receive a "No" response? Y N/A N/A
SK.3 - Complete & Correct Resolution (LW - Efficiencies) 3 of 3 = pass
3.0 Reviewed existing documentation when necessary Y N/A N/A
3.1 Asked probing questions to ensure understanding of the caller's issue Y N/A N/A
3.2 Resolved the caller's issue, first call, and member did not need to be transferred Y N/A N/A
Did more than one component receive a "No" response? Y N/A N/A
SK.4 - Closing (LW - Improved Demeanor; Efficiencies) 2 of 3 = pass
4.0 Offered further assistance Y N/A N/A
4.1 Offered survey(s) / Provided Interaction ID/Case Number (provider calls) Y N/A N/A
4.2 Thanked caller, branded call with the specific plan name Y N/A N/A
Did more than one component receive a "No" response? Y N/A N/A
SK.5 - Service Recognition doesn't require pass/fail
5.0 Provided exceptional service to the customer and deserves special recognition from leader Y N/A N/A
(Auditors: for yes responses, please justify)
 2020/2021 Centene Enterprise Call Quality Form - Membe
Compliance (90% Pass Expectation)

1 - Call Information
Reason for Call:
Inquiry Type:
2 - Adheres to all HIPAA and PHI guidelines - 30 pts
a. Correctly verifies caller, member, and any authorized personal representative
b. Released PHI or PII following appropriate caller verification
c. Did any subcategory receive

3 - Provides all required disclaimer/education text language - 10 pts

a. OMNI/CareConnects disclaimers and educational texts were read to caller/member
b. Did any subcategory receive

4 - Provides accurate information pertaining to plan program and policies - 10 pts

a. Provides or confirms accurate information to include EOC/SOB/Plan Website information (outside of Omni/CareC
b. Provides a correct timeframe (outside of Omni/CareConnects)
c. Did any subcategory receive

5 - Resolves caller inquiry to the extent possible - 15 pts

a. Adheres to established work processes by performing all necessary actions and steps to resolve the caller's inquiry
b. Correctly assesses the reason for the call
c. Transfers the call when needed
d. Addresses all caller/member requests
e. Did any subcategory receive

6 - Adheres to critical business processes - 10 pts

a. Documents the call
b. Documentation logged is not purposely misleading (fraudulent notes)
c. Did any subcategory receive

7 - Adheres to any State specific requirements - 10 pts

a. Adheres to State specific requirements
b. Did any subcategory receive
8 - Interaction Handling - 15 pts
a. Correctly handles an emergency or crisis call
b. Refrain from call avoidance, intentional disconnection, or ensure the call has ended appropriately
c. Refrain from disparaging remarks about program or policies
d. Refrain from member abrasion (e.g., arguing, over talking, condescending/rude manner)
e. Refrain from treating the caller differently based on race, color, national origin, age, disability, or sex.
f. Did any subcategory receive

Service Skills (Categories Passed: 4 of 4 = Exceeds; 3 of 4 = Meets; Less than 3 = Does

9 - Greeting
a. Answered within 3 seconds, branded the call, and provided name in the greeting
b. Offered assistance in greeting ("How can I help you today?")
c. Acknowledged the caller's issue ("I'd be happy to help you with that", etc.)
d. Asked the member if any contact information has changed recently (as appropriate for Legacy WellCare)
e. Service Skill Verification Questions:
Asked if member has other health insurance
Verified and updated PCP (Primary Care Physician)
Addressed any relevant Care Gaps
f. Did any subcategory receive a "Does Not

10 - Communication Skills (5 of 5 = Pass)

a. Empathized with the caller when appropriate
b. Developed rapport with the caller (used the caller's name, etc.)
c. Demonstrated courtesy and respect
d. Demonstrated active listening
e. Provided information in a confident, clear, and efficient manner
f. Did any subcategory receive a "Does Not

11 - Complete & Correct Resolution (6 of 6 = Pass)

a. Reviewed existing documentation when necessary
b. Asked probing questions to ensure understanding of the caller's issue
c. Resolved the caller's issue, first call, and member did not need to be transferred
d. Selected all appropriate Omni intents/CareConnects call drivers in the system
e. Selected and completed all the applicable radio buttons/fields correctly
f. Promoted self-service options relevant to the call
g. Did any subcategory receive a "Does Not

12 - Closing (3 of 3 = Pass)
a. Offered further assistance
b. Offered survey(s)
c. Thanked caller and branded call with the specific plan name
d. Did any subcategory receive a "Does Not

13 - Service Recognition
a. Should the CSR be recognized for exceptional service? (Auditors: If yes,
 Points Points
ices Earned Possible

Member:

Call
Yes / No 30 30

No 30 30

Yes / No 10 10

No 10 10

Yes / No 10 10

No 10 10

Yes / No 15 15

No 15 15

Yes / No 10 10

No 10 10

Yes / No 10 10

No 10 10
Yes / No 15 15
C.7.3

No 15 15

Points Points
%(Score)
Earned Possible
100.00% 100 100

Exceeds/Meets/Does Not Meet/N/A

Exceeds/Meets/Does Not Meet/N/A

Exceeds/Meets/Does Not Meet/N/A

Exceeds/Meets/Does Not Meet/N/A

Overall Service Skills Rating

N/A