Waiver Verification & Audit Training · 2019-06-20 · SPARTACUS – Waiver Verification Spartacus...

Waiver Verification & Audit Training

Training and Development

Page 2 WaiverManualV4 Rev.6/13/2019

OBJECTIVE Know how to effectively handle waiver verifications, auditing, and associated inbound and

outbound calls, in support of Wellfleet’s Waiver Verification & Audit process.

SUPPORTING OBJECTIVES ● Navigating Spartacus to accept, decline, or skip waivers

● Accepting or declining waivers when confirming benefits

● Utilizing phone etiquette tips provided

● Logging in to waiver queue to handle incoming waiver calls

● HIPAA, Login Questions, Waiver Approvals, Waiver Denials, International Waivers


WAIVER VERIFICATON & AUDIT OVERVIEW

CSR/Waiver Verifiers are responsible for waiver verification, auditing, and the associated customer

service during each enrollment period.

Many colleges and universities require that students have adequate health insurance coverage.

Students are given the opportunity to waive the insurance during the Fall, Spring, and/or Summer open

enrollment periods.

Students waiving the insurance must document proof of coverage by submitting an online waiver

through wellfleetstudent.com on their school’s landing page. Verification is done via a real time

electronic data interchange (EDI), Dorado, or by phone. Real time waiver results will be displayed back

to the member within 15 seconds with an approved or pending status. Waivers that can’t be verified by

Dorado in real time go into pending status and are verified manually through the Dorado portal or by

calling the insurance company.

With waiver audit, Waiver CSRs will audit student policies in accordance with “school specific

requirements” or Wellfleet guidelines if school guidelines do not exist. Dorado verification is shut OFF

and select carriers are verified manually through the Dorado portal while all others are by calling out to

the insurance company with either a school specific or Wellfleet audit script.


Turnaround times for pending waivers are as follows: Domestic 3-5 business days and 5 business

days for International students (once all information is received). International students need to send a

copy of their plan’s Benefits and Exclusions to [email protected] for review. See pg. 34

for info on Intl waivers.

*If students cannot provide proof of such coverage, they will automatically be charged for the

student health insurance. This charge will be placed on their tuition bill.


SPARTACUS – Waiver Verification

Spartacus is a web-based application; Chrome is the preferred browser of choice. We can only make

insurance edits in Spartacus (SI) when using it. Internet Explorer & Microsoft Edge can be used for

viewing.

A username and password will be provided to you for access into the system.

System Login


Once you have logged into the system; a home page will be displayed. You will access your work

through the Waivers tab.

Home Page


Make sure you are in the correct School Year. Then select ‘Waivers Pending (All)’


A list of schools with pending waivers will appear, along with other filter options:

To access pending waivers, click the name of the assigned school or click on the ‘Pending # of days’

column for your assigned school.


After choosing your assigned college you

need to modify this search screen.

Change “Insurance Co” and “Show” to

ALL & change coverage period based on

the school you are verifying. You can also

utilize “Order By” to sort the waivers by

carrier.

The performed search will then display a list of students that you will be responsible for working.

You should work according to color:

• Red (previously declined) and yellow (skipped) items were previously received and reviewed and should be worked on first.

• Gray items are waivers not yet looked at.


Accepting Waivers

The waiver will be accepted when you are able to confirm the student has adequate and active coverage; schools have different requirements. See Waiver Verification Spreadsheet for schools’ waiver requirements.


If you can verify alternative coverage, you will accept the waiver by selecting the ‘Accept’ button. A pop-up message will appear asking you to confirm the selection. *Make sure you are accepting the correct student’s waiver.

Once accepted, an email will be sent to the student, which will be available to view for CSR’s and schools under the communication tab on the student’s Spartacus record.

Accidental Approvals Let the Waiver Team Lead know right away, with the name of the person, the school, an approximate time it was approved and the reason the waiver should be denied. Team Lead will: - Contact the account manager so they are aware, and they can notify the school about the students

change in waiver status. - We will need to call the student, letting them know their status has been changed


o Phone number available on the student’s record under Spartacus Tab, Admin Portal (See pg. 25)

Declining Waivers

The waiver should be declined when you are unable to confirm the student has adequate or active coverage with the insurance company you contacted. You may run into discrepancies regarding the date of birth (DOB), subscriber/member/policy holder ID, or insurance company telephone number. Each situation may require further investigation on your part. **NOTE** If the waiver was approved in the fall, please do not decline it for the spring/summer unless the policy has terminated. Please do not give the termination date in your decline reason.

Reasons for Declining

Invalid Member/Subscriber ID Number

When the Subscriber/Member/Policyholder ID number is not correct, you may “Decline” for ‘Invalid Insurance Member/Subscriber Number.’

If it is an Aetna plan, and the student uses an ID number starting with the letter’ W’ followed by only four (4) numbers, you will also “Decline” for ‘Invalid Insurance Member/Subscriber Number.’ You should also include a note stating ‘The 'W' and all 9 digits are needed to verify your coverage, please correct and resubmit.’


Please keep in mind, only Aetna ID numbers starting with the letter ‘W’ should be declined for this ‘note’ reason, as there are nine (9) digits in the complete ID number, and all are needed to verify the coverage. This would be one (1) time you may add a note to a student’s denial.

Invalid Address

An incorrect address may differ because a home address vs. a college address may be listed. Explain we are trying to verify eligibility as they are college students, and that may be the reason the address differs. In some cases, this explanation satisfies the insurance company and they will provide the verification. In the event it does not, “Skip” the student and indicate the reason as “invalid student address.”

Date of birth

For inaccuracies with the date of birth, you may have two circumstances that arise.

Outbound Calls: The company may state, “we show Joe Student as an insured member, but that is not the DOB we have on file” or “we don’t have anyone listed with that DOB.” You may inquire as to if what we have is close and that we will get the student to update his DOB with them or us but ask them if they show Joe Student active.

Other: Another instance of inaccurate DOB may be when using an automated system (Dorado or Phone Call). If this occurs, please do not automatically decline the waiver. Speak with a customer service representative directly.

If they still don’t verify, “Decline” for ‘Invalid date of birth for insured’ from the denial dropdown list. Additional wording has been added in the background to go out on the denial email stating: “The DOB


you gave us does not match what the insurance company has on file. Please contact your insurance company directly & update your declined waiver.”

Invalid Telephone Number

Do NOT decline any waivers for ‘invalid telephone number’ without first checking the carrier phone number pdf or general web to investigate if there is a valid telephone number available.

How to decline

Should you need to decline the

waiver, choose a reason by

selecting the ‘Reason’ from the

drop-down box.

You should always use a reason

provided whenever possible. Should

none of the reasons apply, you will

have the ability to use the free form

Notes field.


* Free Form denials should be limited and only used if you feel comfortable with your reason.

If you type a decline reason in the Notes field under the Reason ‘Other’, be sure the spelling and

grammar are correct. The student and school will receive this denial reason

*See Freeform Waiver Decline Reasons for free form denial wording:

\\athena\z$\Waiver Dept\WaiverVerificationReferenceDocs\ FreeformWaiverDeclineReasons.docx


Skipping Waivers

You will also have the option of selecting ‘skip’. When you do so you will need to provide a short reason for skipping, initials, date and then confirm the skip before proceeding. You can go back to these later to try and reverify

You can skip a waiver:

• If customer service at the insurance company will not provide any information because the student’s address is incorrect.

• For hold times over 5 minutes

• If you are unable to verify coverage due to incorrect telephone number, or if an office is closed.


TELEPHONE ETIQUETTE

The following are some important tips to use each day.

Speak clearly:

You may be nervous with your first few calls. Remember to speak slowly and clearly so the person on the other end can understand you.

Listen closely:

Remember that your listening skills are just as important as speaking. This will reduce the number of times you have to ask someone to repeat what they have already said.

Avoid food or beverage:

From time-to-time we all try to slip a sip or bite in while we sit on hold. Please avoid doing this so you are not caught off guard when it is time for you to respond.

Minimize any background noise whenever possible

Please keep in mind you will be contacting insurance companies and it is common to be transferred multiple times throughout a call. For incoming calls, you will be dealing with students for whom this may be their first encounter with Health Insurance. Sometimes this becomes frustrating. You should avoid showing any frustration to the person on the other end of the line.


Phone Verification

OUTBOUND CALLS Waiver Verification for insurance that cannot be done via Dorado is done telephonically. You will be making outbound calls to various insurance companies to verify students have adequate coverage. With this function comes the responsibility of professional phone etiquette skills.

Telephone calls are recorded and monitored so it is important that you make the proper selection regarding coverage, as audits will be performed on random students.

Here are some important tips to remember as you place calls to each insurance company:

• We are not calling from a provider’s office. When a representative answers, explain that you are not the member, but calling from the insurance company.

o “The insured does not have coverage with us. We administer the Student Health Insurance for the College/University that the member is attending. The insured is opting to waive our coverage, so we are verifying that he/she has other insurance.”

• When you reach an automated system, choose the “member” option, not the provider option.

• We are verifying medical eligibility; some schools have certain requirements for benefits. Refer to the waiver verification spreadsheet for those.


SAMPLE CALL SCRIPT-VERIFICATION The call script below can be used to help you navigate through the verification calls. It is not required that you follow these scripts verbatim, but this sampling provides information you are likely to be asked during your call.

Insurance Company: “Thank you for calling Acme Insurance. Are you the member or a provider?”

Waiver Verifier: “My name is Jane; I’m calling from an insurance company to verify medical coverage/eligibility.

Insurance Company: “What is the name of your company?”

Waiver Verifier: “Wellfleet.” (If asked, the Tax ID number is 04-3187843 and the return telephone number is 877-657-5030.)

Insurance Company: “Does the member have coverage with you?”

Waiver Verifier: No, we administer student health insurance for the college/university that the member attends. He/she has opted to waive our coverage. Can you confirm that the member currently has active health insurance coverage with your company?”

Insurance Company: “Yes. We show this member has had active medical coverage/eligibility since 1/1/2019.”

Waiver Verifier: “Thank you”


TIP: If the insurance company requests the insureds’ mailing address, you can find this information by clicking the ‘decline’ button. You should then click back or cancel to return to the waiver screen. Also visible under the Admin Lookup screen and click pending waiver.

COMPANY INFORMATION As you verify waivers, the insurance companies you contact will ask a series of questions before they agree to release information to you.

Company Name: Wellfleet Company Type: Insurance Company Federal Tax ID: 04-3187843 Telephone Number: 877-657-5030


SAMPLE CALL SCRIPT-AUDIT The call script below can be used to help you navigate through the verification calls. It is not required that you follow these scripts verbatim, but this sampling provides information you are likely to be asked during your call.

Insurance Company: “Thank you for calling Highmark Insurance. Are you the member or a provider?”

Waiver Verifier: “My name is Jack; I’m calling from an insurance company to verify medical coverage/eligibility.

Insurance Company: “What is the name of your company?”

Waiver Verifier: “Wellfleet.” (If asked, the Tax ID number is 04-3187843 and the return telephone number is 877-657-5030.)

Insurance Company: “Does the member have coverage with you?”

Waiver Verifier: No, we administer student health insurance for the college/university that the member attends. He/she has opted to waive our coverage. Can you please provide the effective and termination date, if any, of the member’s insurance?”

Insurance Company: “Yes. We show this member has had active medical coverage since 1/1/2019 with no term date as of yet.”

Waiver Verifier: “Does the member have full ACA (Affordable Care Act) comparable coverage in the state of (provide state school is located in)?”


Insurance Company: “Yes”

Waiver Verifier: “Thank you”

TIP: If the insurance company requests the insureds’ mailing address, you can find this information by clicking the ‘decline’ button. You should then click back or cancel to return to the waiver screen. Also visible under the Admin Lookup screen and click pending waiver.

COMPANY INFORMATION As you verify waivers, the insurance companies you contact will ask a series of questions before they agree to release information to you.

Company Name: Wellfleet Company Type: Insurance Company Federal Tax ID: 04-3187843 Telephone Number: 877-657-5030


Inbound Queue Calls

When receiving calls from students/parents, this may be their first experience with not only Student Insurance, but the waiver process. We also need to remain HIPAA compliant, so we should not give out personal information to anyone except the covered student.

HIPAA What is HIPAA? Health Insurance Portability and Accountability Act of 1996

It is a broad federal law that addresses many health care privacy, security and electronic billing issues; impacting health care providers, carriers, clearing houses, employers with self-funded plans and other business associates.

Our focus is to protect member information. While this course focuses on waivers it is important to only

share the minimum necessary information with callers. Let the caller advise you of the members

information such as student id #, email address, date of birth etc… You can give hints but should not

give out personal member information.

Examples:

• You can say .edu email address or gmail account but do not give out the full email address

• You can advise starting number or letter of school id


Logging into Queue

Your phone will have a Waiver button which must be selected to log into the queue.

Primary Call Center Agents - Waiver

Logging In and Out:

To log into ALL OF THE call center group(s) that you have access to:

• Find the programmed WAIVER Login button. Both the green and red LED’s will be dark.

• Press the ACD Login button.

The GREEN LED lights up, to show you’ve joined your group(s), as well as “G” on the phone display screen; you will start receiving calls directed to all of the group(s) you’re pre-designated to join each day.

To log out of the call center group(s):

• Find the programmed WAIVER Login button on the home screen of the phone. The GREEN LED should be lit to indicate you are logged into the call center group(s) presently.

• Press the group “Log-in” button. The button’s GREEN LED goes dark.


Making yourself Busy/Not Available

By default, the next call in queue will not be presented to your phone until after a short period of “busy wrap-up” time following your previous “call center” call. In the event you will need to extend the length of time before you can take the next call in queue, use the

programmed DND button.

• To Enable: Press the programmed DND button. The GREEN LED lights up, and an “N” appears after your name on your display screen. You will still receive calls from other users, as well as any direct calls transferred to you by another user or the corporate auto attendant.

• You can still use the phone to make outgoing calls; when you go off-hook you will hear stuttered dial tone.

• To Disable: Press the DND button again. The GREEN LED goes dark.

• Waiver Queue Voicemail Retrieval: • Voicemail must be checked daily and returned within 1 business day. To check the voicemail hit *17 on your phone. Enter extension 303#

password 0303#. You will be presented with an indication of new/old/saved messages. Follow the prompts to listen to the voicemails.

• Use the up and down arrow keys to highlight which type of messages (New, Old or Saved) you want to listen to, and press Select or OK

key, or the adjacent feature key. The details of the first message of that type are displayed.


Inbound Calls Scripting

Proper Greeting/Opening:

• “Good Morning/Good Afternoon. My name is (First Name Only). How can I help you or To whom am I speaking with?

• Ask for student ID, school or name to search the student in Spartacus.

*Make sure the person on the phone is the student, we should not give out personal information to anyone except the covered student.

If caller is a Parent/Spouse/3rd party:

- You can assist with waiver, provide directions on how to waive, but cannot give out any personal details or information about the member. *Do not advise waiver status without member verbal authorization

o Can provide hints for email such as .edu or gmail account, as well as the starting number or letter of school/student ID

o Should not reset account password for anyone other than the member

Proper Closing:

• “Thank you for calling Wellfleet”

**Please provide a brief note in the Admin Portal field as to who called and the reason for their call. ---- Located under Spartacus Tab. See page 28 for instructions


Call Queue’s

• Waiver X 303 • Schools X 301 • NYU X 305 • Employer Group X 309

• Large Schools (JHU, Umass, UNLV, UW-Madison) X 311 Spartacus Navigation To view a student’s account, you can use ‘Quick Find’ and search with Student ID or full name of the student.

Admin Lookup is another search option, by searching for the school name here.


Search the student in the criteria field - Full or partial Name - Full or partial email - ID#

You can view the approved, pending or declined waiver by clicking the status under Enroll Status


A waiver will look like this:

If the waiver was denied the reason it was denied will show underneath the verified date.


To view the students account, click the ID# under View. You may need to reset the student’s password, so they can access their account - Go to Spartacus tab and Reset Password. The student will have to go to the student sign-on page and create new account. - If they haven’t ever logged in, they will need to create an account


To make a note on the account While in the students account, go to the Spartacus Tab, click Administration Portal.

A separate screen will pop up where you will be able to see additional student info, any changes to the record, and a notes section.


Make a quick note of the call and scroll down to click ‘save’. Your name and date/time will also be recorded after the message.


Confirmation Email

Students will receive an email confirming whether the waiver is pending, accepted, or declined, and for what reason. The email will be sent to the student’s email on record.

You can view or resend the approved or declined emails under the communications tab while selecting the “Actions” drop down button.

*Declined emails will show the insurance info and the reason the waiver was declined. *For students who are creating their account for the

first time (on an open site), an email is sent but it is not stored in the student’s communications.


International Waivers

Not every school allows waiver auditing for International Students. Refer to the Verification Spreadsheet or Installation Checklist on Spartacus for school requirements.

The SI Waiver Verification & Audit Guidelines provides a standard International Waiver Requirement for schools that don’t have specific requirements.

• All international waivers will be audited. International waivers will be in pending status until

required documentation is submitted and reviewed.

• Students must complete a waiver at www.wellfleetstudent.com on their school’s landing page before the waiver deadline and submit all requested documentation to the waiver mailbox at [email protected] .They will be instructed to send an email with an English language version of their Certificate of Coverage letter, including Benefits & Exclusions from the insurance company showing the dates of coverage and enclose a receipt of payment.

http://www.wellfleetstudent.com/

mailto:[email protected]


The following Wellfleet guidelines will be applied unless the school requests otherwise:

• Coverage must be effective on or before the school published waiver deadline, and extend through

the semester, including breaks and holidays. For schools verifying waivers for each semester,

existing coverage through 12/31 will satisfy Fall waiver requirements even if the school term

extends into January. For schools verifying once per school year, coverage through 4/30 will

satisfy the annual waiver requirement.

• International health insurance coverage must be UNLIMITED per accident/illness and comparable

to the Wellfleet Student Health Insurance Plan (SHIP). It must meet ALL of the following minimum

coverage requirements (all amounts are in USD). Travel insurance is not acceptable due to

plan limitations.

A. Coverage for emergency and non-emergency care in University area

The plan must provide medical benefits (doctor visits, surgery, laboratory tests, x-rays, etc.) for each

accident or illness.

B. Coverage for inpatient and outpatient care in University area

The plan must provide medical coverage for both inpatient (stay at an inpatient facility/hospital) and

outpatient (doctor’s office, outpatient department of a hospital or ambulatory surgical center, urgent

care, etc.) services.


C. Coverage for immunizations and maternity as mandated by the ACA (Affordable Care Act)

D. Prescription Drug Coverage

E. Coverage for pre-existing conditions with no waiting period

The plan cannot exclude coverage for any pre-existing conditions.

F. Coverage for mental health and substance abuse

G. Unlimited aggregate maximum benefit per policy year per covered person. There should never

be inside limits for any plan approved.

H. Repatriation/Medical Evacuation Coverage – A combined benefit of $100,000 minimum.

The plan must provide at least $100k combined to send the body/remains back to the student’s home

country.

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Waiver Verification & Audit Training · 2019-06-20 · SPARTACUS – Waiver Verification Spartacus...

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