1.
Federal law that protects sensitive patient health information from being disclosed without consent.
2.
A joint federal and state program that provides health coverage for some people with limited income and resources.
3.
The federal health insurance program for people who are 65 or older or have certain disabilities.
4.
The specific items or services covered under a member's health insurance plan.
5.
The status used to determine if a person qualifies for coverage or a specific program.
6.
The individual person who is enrolled in and covered by the health insurance plan.
7.
A doctor, hospital, or healthcare professional authorized to provide medical services.
8.
The call center agent responsible for assisting callers and resolving their inquiries.
9.
Formal requests sent by a provider to the insurance company for payment of services rendered.
10.
The amount a member must pay out-of-pocket for covered services before the insurance plan begins to pay.
11.
The omnichannel contact center platform used by agents to manage calls and member interactions.
12.
The security process of verifying a caller's identity before accessing or discussing private account details.
13.
A resource library for agents to search call topics for guidance.
14.
The act of recording clear and concise notes in the system regarding a member's call or request.
15.
The status of a policy or membership that has been terminated or is no longer in effect.
16.
The status indicating that a member’s insurance coverage is currently valid and in force.
17.
A member who is "dual eligible" and receives benefits from both Medicare and Medicaid.
18.
The formal process of verifying a provider's professional qualifications, such as licenses and certifications.
19.
Created first in CRM to authenticate and document a call when received
20.
The process of transferring a call to a supervisor or specialist when a complex issue cannot be resolved by the initial agent.
21.
Short for prior authorization, a requirement for approval from the plan before certain medical services are performed.
22.
A formal complaint filed by a member regarding the quality of care or service they received from their plan or provider.
23.
A major health insurance company known for providing Medicare Advantage and Medicaid plans across the country.
24.
The performance measurements used to track and analyze call center effectiveness and agent efficiency.
25.
A fixed amount, such as $20, that a member pays for a covered healthcare service after paying any applicable deductible.
26.
The percentage of costs—for example, 20%—that a member pays for a service after they have met their yearly deductible.
