BCRC Call Center Quality Guidelines Notes

Document Control and Revision History

• Document Title: BCRC Call Center Quality Guidelines

• SOP Number: COBR004

• Version: 8.1

• Prepared By: General Dynamics Information Technology (GDIT)

• Effective Date: $05/01/2020$

• Revised Date: $06/12/26$

• Standard Process Overview:

  • Related documents include all Call Center processing standard operating procedures (SOPs), work procedures (WPs), tools, guidelines, and system manuals.
  • The information in the SOP is not all-inclusive; CSRs must exercise judgment and contact supervisors for situations not explicitly outlined.

• Summary of Document Changes:

  • 05/01/20: Updated for BCRC2 contract (K. Lau).
  • 03/11/21 (ICR31311-2.0): Adjusted scoring/description for Part I HIPAA/Privacy; added IVA under Telephone Etiquette; adjusted Scoring-Part II retroactively to $2/01/21$ (B. Gallardo).
  • 10/01/21 (ICR31642-3.0): Emergency Elevate; changes under "Keep Caller Informed"; updated IVA section; other minor adjustments (Donna Flohra-Vandeventer).
  • 02/28/22 (ICR 31726-4.0): Minor modifications for requirement clarification retroactively to $1/1/22$ (Donna Flohra-Vandeventer).
  • 05/23/22 (ICR 31788-5.0): Updates and clarification for "Remain Attentive to Customer’s Needs" (Donna Flohra-Vandeventer).
  • 07/03/23 (ICR 32052-6.0): Update for CSR to provide fax number and mailing address for documentation submission (Peterkay Smith).
  • 08/11/23 (32019-6.1): Documented 2022 annual review approval (J. Paszkiel).
  • 02/26/24 (32192-7.0): Added footnote for "Appropriate Closing" (Donna Flohra-Vandeventer).
  • 07/24/25 (32529-8.0): Updates under "Show Willingness to Assist"; moved "Beneficiary Contact #" update; added footnote under appropriate closing (Milik Dawkins).
  • 06/12/26 (32727-8.1): Changed the term “agent” to CSR (W. Sykes/J. Paszkiel).

Introduction and Role Expectations

• Purpose: To provide Customer Service Representatives (CSRs) with a clear understanding of role expectations. Exceptional service includes:

  • Providing information to satisfy inquiries.
  • Updating the Common Working File (CWF) to ensure correct claim payment.
  • Effectively documenting activities for reference.
  • Maintaining the integrity of the Medicare Trust Fund.

• Skill Set Definitions:

  • Technical Skills: Based on operational knowledge and proficiencies.
  • Call Etiquette: Measures interpersonal communication and the ability to deal effectively with people.

• The BCRC CSR Identity: CSRs are the “voice” of the Benefits Coordination and Recovery Center. Success is determined by providing a seamless experience where customers feel confident.

• Core Responsibilities:

  • Assist customers with BCRC-related issues.
  • Authenticate all callers in the Beneficiary Information Line (BIL).
  • Ensure accurate updates to records and screens.
  • Offer educational advice regarding the BCRC program and health coverage.
  • Ensure exceptional customer satisfaction.

• Unacceptable Behaviors:

  • Using profanity.
  • Hanging up on a caller.
  • Making negative comments about staff, policies, or government agencies.
  • Irate or condescending behavior.

Part I: Defining CSR Expectations - HIPAA and Technical Skills

Adherence to HIPAA and the Privacy Act ($25\,\text{points}$)

• Definition: Medicare contractors must protect the privacy of beneficiary records under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Privacy Act.

• Process: Identify caller type, secure validation info, and provide authorized info per the Disclosure Desk Reference (DDR) and Authorizations SOP.

• Authorized Documentation Types: Include verbal and written authorization, Proof of Representation (POR), Consent To Release (CTR), and Blanket Authorizations.

• Deduction Errors ($25\,\text{point}\,\text{deduction}$):

  • Invalid / No Authorization: Caller is not the beneficiary and no authorization is on file.
  • Expired Authorization: Filed authorization is out of date.
  • Deceased Beneficiary: Updated authorization or credentialing documents are missing post-death.
  • Not Authenticated: CSR failed to obtain all required elements per the DDR.

• Specific Authentication Elements Required:

  • Beneficiary: All $4$ elements: Health Insurance Claim Number (HICN), Name, Date of Birth (DOB), and Address/Entitlement date/Phone number.
  • Provider: NPI number and Facility/Doctor name.
  • Employer: Caller Name, Phone, Company Name, Employer Identification Number (EIN), plus all $4$ beneficiary elements.
  • RRE/Contractor: RRE number and RRE name.

Technical Skills: Trust Fund – Probing Questions ($10\,\text{points}$)

• Requirement: Ask specific questions to determine if Medicare is primary or secondary using the Secondary Payer Questionnaire as a guide.
• Probing Categories:
  • GHP/NGHP/PDC: Must ask all questions to determine if a record should be established, terminated, or deleted.
  • Size Test: Required to determine if MSP is applicable.
  • Verification: Must ask for Retirement Date, Coverage End Date, Date of Loss (DOL), and Injuries (DX codes).

Technical Skills: Accurate Information and Updates ($10\,\text{points}$)

• Knowledge Requirements: CSRs must explain:
  • Medicare Secondary Payer (MSP) and Recovery laws.
  • BCRC policies and BCRS application (why info was reported, authorization needs).
  • Rules for Working Aged, Disability, and ESRD.
  • RRE processes via Data Sharing Agreement (DSA) and MMSEA Section III.
  • Interactions between different Medicare contractors.
  • Correspondence: Confirmation letters, CPLs, NOS letters, and Demand amounts.
• Action Errors ($10\,\text{point}\,\text{deduction}$):
  • Failure to delete duplicate records.
  • Completing the incorrect MSP questionnaire section.
  • Failing to verify Employer/Insurer before updating.
  • Failure to add termination dates or update records consecutively.

Technical Skills: Follow-up Information/Actions ($10\,\text{points}$)

• Requirements:
  • Explain timeframes for claim submission, CPL mailing, and pre-demand/post-demand disputes.
  • Explain the crossover process for secondary supplemental insurance.
  • Advise on waiver and redetermination requirements.
  • Instruct on including HICN/SSN on correspondence.
  • Instruction Detail: Advise that providers can resubmit denied claims after $10\,\text{days}$.
  • Contact Info: Provide BCRC fax and mailing address when documents are required.

Call Etiquette: Interpersonal Communication Standards

Greeting ($5\,\text{points}$)

• Mandatory Elements:
  • Brand as “Benefits Coordination and Recovery Center.”
  • State first name and identification number.
  • Ask for the caller’s name and nature of the call.
• Protocol for Silence: If silence occurs, repeat greeting and inform the caller you cannot hear them; provide hours of operation and return number.
• Third-Party Rules: If a third party joins, the CSR must introduce themselves with their name and ID number.

Use of the Caller’s Name ($5\,\text{points}$)

• Standard: Use the name (first or last) throughout the call to build rapport.
• Prohibited: Using pet names (sweetheart, honey) or nicknames without the caller initiating them (e.g., calling Robert ’Bob’ without permission).

Show Willingness to Assist ($5\,\text{points}$)

• Actions: Educate, suggest solutions, empathize, and verify beneficiary contact info.
• Resource Provision: Provide numbers/hours for $1$-$-800$-Medicare, Social Security, and websites (MyMedicare.gov, Medicare.gov, Medicare & You Handbook).
• Empathy Examples: Acknowledge loss of a family member; apologize for frustrations or multiple transfers.

Demonstrate Professionalism ($5\,\text{points}$)

• Standards: Pleasant tone, clear grammar, and gauging speed to the caller.
• Avoidance List: Profanity, reading out loud to oneself, projecting sighs, and interrupting.
• Jargon Policy: Use industry acronyms (CPL, NOS, HICN) only if the caller initiates or if the caller is a Professional (Provider, Insurer, RRE).

Keep the Caller Informed ($5\,\text{points}$)

• Objective: Prevent unexplained silence.
• Hold Protocol:
  • Ask permission and wait for an answer before placing on hold.
  • Check back with the caller every $2.5\,\text{minutes}$.
  • Use the mute button only after informing the caller you are reviewing records, and check back every $2.5\,\text{minutes}$.
• Transfer Protocol: Ask permission and state the destination department before transferring.

Remain Attentive to Caller’s Needs ($5\,\text{points}$)

• Techniques: Active listening, responding to all questions, and guiding off-topic callers back to the resolution.
• Tools: Use BIL for authentication to ensure efficiency during transfers.
• Prohibition: Refrain from personal stories or providing personal opinions.

Appropriate Closing ($5\,\text{points}$)

• Process: Recap the call, advise on resolution/next steps, and ask for further questions.
• Branding: Must thank the caller for calling the BCRC.
• Exceptions: For internal transfers (ESRD, Recovery, Spanish, Supervisors), the CSR is not required to offer additional assistance.
• Disconnecting: If the call is complete or the caller asks to be released from a $3$-way call, offer assistance, close, and then disconnect.

Phone Documentation and Evaluation

Phone Log Standards ($5\,\text{points}$)

• Requirement: A phone log is mandatory for every call to provide an audit trail.
• IVA Tool Required Fields:
  • Caller’s Name and Phone Number.
  • Relationship (e.g., Beneficiary, Attorney, RRE, Employer).
  • Work Area (Recovery or Data Collection).
  • Wrap-Up Code and Standard Notes.
  • Specifics: When terminating a record, notes must include the Date of Incident (DOI) and the termination date.

Intelligent Virtual Assistant (IVA) Tool ($5\,\text{points}$)

• Mandatory Use: Effective $10/01/2021$, IVA must be used on all calls.
• Deductions: Occur if the tool is not open, not used for the phone log, or if the CSR discusses the tool with the caller.

Part II: Scoring and Feedback

• Scoring Grid Total: $100\,\text{points}$.
  • HIPAA: $25\,\text{points}$.
  • Technical Skills: $30\,\text{points}$ total ($10$ each for Probing, Accuracy, Follow-up).
  • Call Etiquette/IVA/Logs: $45\,\text{points}$ total ($5$ each for Greeting, Name, Willingness, Professionalism, Informed, Attentive, Closing, Log, IVA).
• Coaching: Evaluations are performed monthly. Results are sent to the CSR and Supervisor. Follow-up coaching sessions are mandatory to discuss calls in detail.

Part III: Closing Summary

• Summary Goal: Guidelines ensure CSRs assist and educate callers accurately. They provide a structural framework for identifying critical areas of call handling while acknowledging that not all calls are identical.