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Participant Services Representatives

PHP’s Participant Services Representatives responsibilities include, but are not limited to, the following:

  • Responding to inquiries about PHP’s operations, covered services, and provider network, including:
    • Eligibility, enrollment, and disenrollment
    • Care management and care coordination
    • Network providers, including hospitals, nursing facilities, ICFs, clinics, physicians, practitioners, and pharmacies
    • Covered services and how to access them
    • UM requirements, including prior authorization guidelines
    • Grievances and appeals 
    • Cultural Competency
    • Participant rights and responsibilities
    • Coordination of benefits, as applicable
    • Privacy and confidentiality
  • Explaining Partners Health Plan’s processes for accessing services and assisting participants in making appointments and arranging transportation
  • Explaining the role of the PCP and providing assistance in selecting one, if needed
  • Developing and distributing participant and family marketing materials, including:
    • The New Participant Welcome Packet
    • The Participant and Family Handbook/Evidence of Coverage (EOC)
    • Provider and Pharmacy Directory
    • Informational brochures and posters, and related materials in a language and format participants and their caregivers are able to understand
  • Connecting participants and their caregivers with available internal and external resources, including community-based resources
  • Providing translation services as needed, including the use of Language Line and NY Relay services
  • Handling emergency crisis or urgent calls for assistance, including referring calls to the Nurse Hotline or other on-call clinicians as appropriate
  • Adhering to protocols and restrictions regarding participants’ clinical information 
  • Clarifying information in the Participant and Family Handbook/EOC and PHP website
  • Fielding and responding to questions and complaints and advising participants and/or their families/caregivers about their right to complain to CMS, the NYS Department of Health, and/or OPWDD at any time
  • Advising participants and their families/caregivers about the grievance and appeals system and the service authorization process
  • Conducting new participant and family orientation sessions and other educational activities
  • Assisting care management staff with health promotion and wellness initiatives
  • Assisting participants with the renewal of their Medicaid benefits 

 

Call Center

PHP’s dedicated toll-free Call Center is available 24 hours a day, seven days per week at 1-855-747-5483 or TTY/TDD: 711. At a minimum, the Call Center is staffed with a live person seven days a week from 8:00 a.m. to 8:00 p.m. eastern time; at all other times the Center employs an interactive voice response system to meet participants’ needs. All voicemail inquiries will be promptly responded to on the next business day. Translation services are also available for participants and/or families/caregivers with limited English proficiency (LEP) and NY Relay and other accommodations are available in accordance with participants’ individual needs. Call Center staff is trained to respond completely and accurately to participant and prospective participant inquiries, issues, and problems regarding their services and has access to clinical staff when a participant has inquiries or issues that are clinical in nature.

The Call Center staff is trained and knowledgeable about eligibility, covered services, participant rights and responsibilities, and grievances and appeals, among other topics. They are also trained to provide information and assistance relating to provider services, community and social service resources, and resolving complaints. Importantly, Call Center staff will not provide actual coverage determinations or decisions on grievances and appeals, but will instead provide information on how the coverage determinations, grievances, and appeals processes work and assist callers to navigate these processes, if requested.

Call Center staff will promptly transfer any participant inquiry outside their scope of authority to the appropriate department within PHP, such as Provider Relations, Medical Management, Claims, and participant complaints and grievances. Call Center staff never provides clinical advice or information as these inquiries are always responded to by appropriate clinical staff. Calls of this nature are instead “soft-transferred” without losing contact with the caller (during business hours) to an appropriate care manager who is trained to understand and assist with their health care needs. At all other times the IVR system phone tree will automatically transfer calls of a clinical nature to a licensed clinician that is trained to provide general health-related information and assistance in accessing services or obtaining service authorizations outside of normal business hours. This service is available 24 hours per day, seven days per week. 


Nurse Advice Line

PHP Care Complete FIDA-IDD Plan operates a toll free nursing hotline with live nurses available to answer health related questions 24/7.  This hotline can be reached at 1-855-769-2507.


Language Translation Services

PHP makes interpretation services available free of charge in any language to any participants and/or families/caregivers that need assistance in understanding oral communications or written materials. Professional interpreters are used as needed to discuss technical, medical, or treatment information. PHP utilizes the New York Relay service at 7-1-1 for communicating with participants and families/caregivers that are deaf or hearing impaired. Written materials are also available in large print, CD-ROM, Braille, and other mediums upon request.


Participant Ombudsman

The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by PHP Care Complete.  The Participant Ombudsman may be reached toll-free at 1-844-614-8800 (TTY users call 711) or online at icannys.org.  

New York State’s FIDA Participant Ombudsman program is designed to assist participants/families/caregivers in accessing covered services, supporting individual advocacy, and conducting oversight for the FIDA program. The Ombudsman’s role is to ensure participants are able to access medically necessary services and supports in compliance with all state and federal rules and regulations. PHP’s obligation is to respond accurately and on a timely basis (i.e., as expeditiously as possible or in compliance with required timeframes, if applicable) to all Ombudsman inquiries and work collaboratively to ensure a speedy resolution to any issues or concerns that the Ombudsman may have.

 


Participant and Family Feedback

PHP strongly encourages participants and their families/caregivers to provide helpful comments and feedback and assist us in identifying any deficiencies and/or opportunities for improvement. You may do so informally at any time by communicating with their care management team, IDT members, or the Participant Ombudsman, or by contacting our Call Center or sending an email or letter. PHP’s staff is responsible for ensuring that all comments, questions, and concerns are communicated to the appropriate individual(s) or department and that accurate responses are provided to participants and/or their representatives on a timely basis.

PHP will also implement more formal mechanisms for eliciting participant and family feedback and involvement in plan governance, including:

  • Community Liaison/Participant Advocate: PHP’s Community Liaison is responsible for maintaining open lines of communication with participants and their families/caregivers, community-based organizations, provider associations, advocacy groups, and other relevant parties through in-person visits, attendance at various events and functions, conducting educational sessions, and engaging in other educational and public relations activities.
  • Participant Feedback Sessions: PHP will conduct participant and family/caregiver feedback sessions at least twice annually in New York City as well as in each county we serve outside of NYC (i.e., Nassau, Suffolk, Westchester, and Rockland) during which attendees will be invited to voice any questions or concerns they may have or to provide helpful feedback about their experience with PHP. PHP’s Community Liaison, Director of Participant Services, Director of Quality Management, and representatives from senior management will attend these sessions. As needed, PHP will assist individuals with any expenses they may incur in attending these sessions and/or provide help in arranging transportation or other needed assistance.
  • Participant Advisory Committee: PHP’s Participant Advisory Committee will meet on a quarterly basis and be open to all participants and participants’ representatives as well as to the FIDA Participant Ombudsman. As needed, PHP will assist individuals with any expenses they may incur in attending these sessions and/or provide help in arranging transportation or other needed assistance and will make all reasonable efforts to ensure that the composition of the Committee reflects the diversity of our participants and families. The Committee will be chaired by the Director of Participant Services and will also include the Community Liaison, the Director of Quality Management, and the Regional Director of Care Management or designees. During these meetings, PHP will communicate any updates or proposed changes to plan operations as well as information about (non-inclusive): The Committee will also actively solicit feedback from the attendees on such topics as service delivery and accessibility, participant satisfaction, quality, Call Center operations, and any other relevant subjects. The minutes of Committee meetings will be distributed to PHP’s Quality Oversight Committee and the Quality Management Oversight Committee of the Board for review and recommendations, as indicated.
    • The number and nature of participant grievances and appeals
    • Quality assurance and performance improvement
    • Enrollments and disenrollments
    • Noteworthy changes in the provider network 
    • State and federal policy updates
    • Upcoming events
  • Board of Directors: At least 25 percent of PHP’s Board of Directors will consist of representatives from participants’ families/caregivers with the same rights and responsibilities as all other Board participants.

 

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Contact us at (855) PHP-LIVE  (747-5483) or TTY/TDD: 711

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