1. What is a Customer Care Associate?

2. The role of a customer care associate is more than just picking up the
phone. The roles and responsibilities include:
• Answering callers questions regarding
benefits, claims payment, providers and
eligibility.
• Analyzing problems and providing information or
solutions.
• Thoroughly documenting inquiries for tracking
and future reference.
• Helping to develop and maintain customer
loyalty. Callers whose needs are met
efficiently, consistently, and in a friendly manner
find little reason to take their business elsewhere.

4. • Providers
• Members Brokers and Agents
• Employer Groups
• Internal Customers

5. 1. PROFESSIONAL PROVIDERS 2. FACILITY
PROVIDERS/INSTITUTIONAL
 Anesthesiologist
 Chiropractor
 Dermatologist
 Family Practice/ Primary Care
Physician (PCP)
 Gastroenterologist Internal
Medicine/ Primary Care Physician
(PCP)
 OB-GYN
 Otolaryngology (Ears, Nose and
Throat or ENT)
 Pediatrician/Primary Care
Physician (PCP)
 Physical Therapist
 Psychiatrist
 Radiologist
 Surgeon
 Ambulatory Surgical Center
 Hospice Center
 Hospital
 Imaging Center
 Laboratory
 Residential Treatment Center
 Skilled Nursing Facility

6. 1. What are the roles and responsibilities of a customer care associate?
2. List three types of customers we served?
3. Anyone who is licensed to render medical services to a patient is called:
a.) Agent b.) Provider c.) Family member d.) Technician
4. Callers whose needs are met efficiently, consistently, and in a
friendly manner find little reason to take their business elsewhere.
a.) True b.) False

7. What types of members are served?
1. Subscriber of the plan (the owner/decision maker of the plan
or policy)
2. Subscriber’s spouse
3. Subscriber’s children (dependent)
4. Subscriber’s grandchildren - In most cases insurance will not
cover grandchildren unless specifically stated on the
subscriber’s contract.
5. Domestic Partner – Male and Female or same sex partner living
together for a certain period. Some states allow coverage for
domestic partners upon meeting certain requirements.

8. Brokers and agents are people who are licensed
to sell insurance. Not only does the broker sell
the policy to the member, they also call in behalf
of the member to resolve a concern that the
member has.

9. Benefit Coordinators often represent the Employer Group when
interacting with their insurance company. Because most
companies have a Benefit Coordinator that acts as a liaison
between the group member and the insurance
company, employees of the company often enlist help from the
Benefit Coordinator in resolving concerns.

10. Who are We?
• Operations Experts Managers Claims
• Processors/Adjusters Grievance and
Appeal
• Associates Enrollment and Billing
Representatives

12. There are two ways to obtain insurance
• By purchasing a policy through a
broker (Individual Policies)
• Through Employment when
employed by a Small or Large Group
company

13. A consideration of the following will be made:
• Age of the person
• Current health condition
• History of chronic illnesses
• History of injuries

14. • The applicant completes an application form obtained
either from their broker or on the internet.
• The application form will be forwarded to the
Underwriting department where the review of
information on the form is performed. There is a high
possibility to request additional information at this
stage. After the review, the application can either be
approved or denied by the Underwriter.
• If approved the member will receive an ID card
together with a copy of Evidence of Coverage (EOC)
explaining the benefits and features of the plan they
chose.

17. 1. List three types of subscriber’s who might have an active
membership with an insurance company.
2. Brokers and agents are people who are licensed to sell _________
3. Certain guidelines apply about what can be discussed with the
coordinator about a member.
a.) True b.) False
4. When contacting a Broker regarding health insurance, will the
family history of the applicant be considered?
a.) True b.) False
5. List two ways a person might obtain insurance.