Page 27
a. Orienting the member to the health plan and assisting members in the selection of a PCP; b. Assisting members to make appointments and obtain services; c. Assisting in arranging medically necessary transportation for members; d. Arranging interpreter services; e. Assisting in reporting fraud, waste, and abuse; f. Assisting members with coordination of out-of-plan services; g. Ordering member materials, such as handbooks and provider directories; h. Explaining to members what to do in an emergency or urgent medical situation; i. Assisting members with questions regarding benefits and how to access services; j. Handling members' complaints, grievances, and appeals; and k. Providing a toll-free telephone number. C. The MCO must maintain a toll-free Member Services telephone number. Although the full Member Services function is not required to operate after regular business hours, this or another toll-free telephone number must be staffed twenty-four (24) hours per day to provide prior authorization of services during evenings and weekends, including pharmacy services. D. Provider Services – The MCO must staff a provider Services function operated at least during regular business hours and responsible for the following: 1. Assisting providers with questions concerning member eligibility status and benefits; 2. Assisting providers with plan prior authorization, care coordination, network questions, and referral procedures; 3. Assisting providers with claims payment procedures; 4. Handling provider complaints.