The QA Help TextBlaze includes the headings of the QA Score Card, the expectations and points associated with each question as well as talking points to assist you in meeting fully demonstrated in each area. Please utilize the radio buttons to show example scripting to assist you throughout the call. The scripting is simply an example or suggestion, please feel free to make it your own so it flows into a tailored conversation with your member.
- HIPAA / Privacy: Correct verification, non-leading questions, correct delegate handling, and recorded-line disclosure when required.
- HIPAA 10 Points: Did the HG protect the members privacy and follow all HIPAA verification and delegate processes? FD PD ND NA
- PD: Leading questions provided or call recording disclaimer missed for OB calls/other member joining the call
- ND: Incomplete identifier (address, Name, DOB), disclosed PHI to a non delegate, OB HIPAA verification missed, Incorrect delegate process
- *Apple customer only requires Zip code for address identifiers.
I'm sorry that isn't the address I have on file have you moved recently?
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I'm sorry, I'm unable to verify, Could you please provide your full legal name?{endformtoggle}
- Clarifying and Expanding Resolve: Ask the questions needed for the right resolution path, then expand only into relevant adjacent support such as benefits, provider help, or network status. A miss is surface-level resolution without the clarifying questions needed for a complete answer.
- Clarifying & Expanding Resolve 4 Points: Did the HG ask appropriate clarifying questions and offer relevant accompanying information to fully resolve the members needs? FD ND
- If the HG missed an opportunity to expand the full resolve for the member or missing important clarifying questions to get the complete resolve for the member, this should be marked as Not Demonstrated.
Just so I understand correctly, can you tell me a little more about... ?
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Have you already received a cost estimate, or are you looking to understand your benefits before scheduling?
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Are you looking for a new provider, a second opinion, or help coordinating care with your current provider?{endformtoggle}
- Benefits Accuracy: Quote the correct coverage for the actual scenario, including key qualifiers when applicable such as routine vs diagnostic, site of care, network level, limits, prior authorization, accumulators
- Benefits 6 points: Describe the benefit in its entirety, including the network deductible, coinsurance and out of pocket. If the benefit differs depending on place of service, that should be mentioned as well. FD PD ND NA
- PD: Missing self-service guidance when applicable, missing OON verification when applicable, missing accompanying benefits, missing confirming the plan limit per benefit (co-ins/deductible amount per InView benefit tile)
- ND: Incorrect benefit information provided, missing tier level coverage, incomplete PA/Pre cert guidance, Missing location (Inpatient, Outpatient, Virtual), Missing routine & diagnostic if not confirmed, missing provisions/limits/exclusions
- Claims Accuracy: Explain how the claim processed in plain language against the member’s benefit and take the right next action when the claim appears wrong or incomplete.
- Claims 6 Points: Did the HG correctly support claims education and review and take the correct steps when needed? FD PD ND NA
- PD: Missed explanation of benefit to how the claim processed, Missed providing a realistic time from for resolution, missed checking network status of provider when applicable.
- ND: Incorrect or missing C&B task or outreach to the HP, Claim explained incorrectly, missed accumulator explanation/balance when applicable, correct claims process not followed
- *Allstate: We cannot review claims with the HP without member present.
- *Apple & 1.0 Clients: HG will ask the member to send EOB/bills as claims feed is not available
- Provider and Network Support: Use the member’s criteria, confirm network status accurately, give the correct disclaimer, and send results when provider support is part of the need.
- Providers 6 points: Did the HG support complete and correct support regarding checking network status and finding the correct options for the member's needs? FD PD ND NA
- PD: Missing asking for provider preferences (gender and zip code), did not give provider network disclaimer
- ND: Provider list has incorrect information, provider list does not match member preferences/requirements, no offer is made to locate relevant providers, incorrect network status is provided etc.
- Clinical Probing and Expanding: Use purposeful open-ended questions to understand symptoms, diagnosis, treatment stage, or care context when clinical need is present or implied.
- Clinical Probing & Expanding 10 Points: Did the HG demonstrate purposeful probing to understand the member's health needs? FD ND NA
- Intent is to ensure effective probing is used to uncover any care needs for the member/family. The intent is to not just answer the members question(s) but to understand their condition, symptom, diagnosis, or stage of care to provide additional and effective value.
Is this a medication you’ve been taking for a while, or was it recently prescribed?
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Have you been able to discuss these [symptoms] with your healthcare provider, or are you still exploring your care options?
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You mentioned a new diagnosis of [diagnosis]. Have you had an opportunity to discuss next steps or treatment options with your healthcare provider?{endformtoggle}
- Barriers: When the member expresses a cost, logistics, fear, language, or other care barrier, address it with practical support, resources, or escalation. A miss is acknowledging the barrier without helping remove it.
- Barriers 5 Points: If the member discloses a barrier to seeking care, did the HG appropriately attempt to resolve and address with the member? FD ND NA Created Barrier
- Programs and THAs: Introduce THAs and relevant program referrals in context, explain value, confirm interest, and share details correctly when appropriate.
- True Health Actions (THAs) 7 Points: Will populate in InView. Effectively addressing a THA includes explaining the value and how this can support the member with an offer and support to assist with effective utilization of the offering. FD PD ND NA
- PD: The THA was introduced but not closed
- ND: Missed introducing a THA for caller/delegate, missed sharing/sending THA, THA sent without introducing, selected incorrect reason for closing a THA
Based on what you’ve shared, you have benefits and resources that may help you navigate your next steps one of them is...
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As your Health Guide, I can help you explore available Transcarent and employer-sponsored benefits, one that might be helpful for your needs is...{endformtoggle}
- Program Referrals 7 Points: Program referrals are relevant options for the member's need. If there was not a relevant program to the member needs or clinical probing did not exist, the expectation is still to introduce at least one program to the member. A program can be an employer sponsored program or Transcarent program. FD PD ND
- PD: Program introduced but missing a valuable and knowledgeable description
- ND: Program sent to the member without introducing, member was not referred to a program, HG misquoted program coverage/criteria, program not sent to the member.
- *If a program was introduced as part of a THA, this is graded under the THA question. For program referral credit, we would like to educate on additional program.
Before we wrap up, can we take a moment to explore whether any other available programs or benefits may be helpful?
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Would you like me to explore whether there are programs available that align with your needs?
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I’d like to make you aware of some programs that may be available to support you throughout your care journey.{endformtoggle}
- Enhance: When clinical value is present, make a tailored connection to the right clinical resource and explain why it fits the member’s situation.
- Enhance 7 Points: If the member discloses a health need that can benefit from clinical engagement, did the HG offer a tailored enhance to a nurse? FD ND NA
Based on what you’ve shared, I’d like to see if we can connect you with a nurse who may be able to provide additional clinical guidance.
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I’d like to make you aware of the option to speak with a nurse who may be able to help you better understand your care options and next steps.{endformtoggle}
- Building Trust: Explain Transcarent’s role and value.
- Building Trust 5 Points: Did the HG effectively deliver a value statement to build trust in our service? FD ND
- The Health Guide should deliver a value statement on every call. If the member is not new or repeat caller, there should be a tailored value statement. If the member is new to our service or confused in our role, a robust value statement should be delivered.
You don’t have to navigate your benefits alone. I’m here to help you understand your options and connect you with available resources. You can reach me through messaging on the Transcarent app or call me at [Client Phone Number] My extension is...
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One of the benefits of working with us is having a resource to turn to when you need help understanding your options or navigating your care. You can reach us at [Client Phone Number] or message us through your Transcarent app anytime.
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Whenever you have questions about your benefits or need help finding available resources, please think of us as a place to start.{endformtoggle}
- Check for Understanding:
- Checking for understanding 4 Points: Did the HG check for understanding when complex information is share or if the member shows confusion? FD ND
How does that sound to you?
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Would you like me to clarify anything before we move on?
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Am I explaining that clearly?
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Does that make sense so far?{endformtoggle}
- Check for Additional Needs:
- Checking for additional needs 3 Points: Did the HG check for additional needs of the member, prior to ending the interaction? FD ND
Have I answered your questions today, and is there anything else related to your health or healthcare benefits that you or your dependents would like help navigating?
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Before we wrap up, can you share whether everything we discussed makes sense and whether there are any other health or benefit needs I can help you explore?
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Have we covered everything you needed today, and are there any other care needs or available resources you’d like me to help you navigate?{endformtoggle}
- Etiquette:
- Etiquette 4 Points: Did the HG demonstrate proper interaction procedures? FD ND
- ND: Please use if the following were present: Repeat caller flag Repetition Member has to repeat themselves Interrupting Long hold time Missed transfer Background noise Disconnection missed call back
- Empathy: Respond to emotional cues with relevant acknowledgment, then continue the resolution path.
- Empathy 4 Points: Was the member met with empathy throughout the entirety of the interaction? FD ND
I can understand how frustrating it must be to have to navigate all of this.
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I'm happy to hear that, thank you for sharing that with me!
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I can appreciate that not knowing what to expect can feel overwhelming.
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That sounds like a lot to navigate, and I appreciate you trusting me with that.
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I hear how upset you are and I understand this hasn’t been the experience you expected. Let’s focus on what we can do next.{endformtoggle}
- Ownership: Reduce burden on the member through proactive action, clear follow-through, and assumptive support when help is within scope.
- Ownership 10 Points: When necessary, did the HG offer to assist with any necessary support for the member's needs? FD ND
Let me look into this for you so we can determine the best available path forward.
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I’ll take ownership of helping you navigate this concern and work to identify the appropriate resources and next steps
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I’ll help facilitate the connection and clarify what to expect next, so you’re not left trying to figure it out on your own.{endformtoggle}
- Expectation Setting: When follow-up or member action is needed, clearly explain next steps, timing, and what will happen next.
- Expectation Setting 3 Points: Did the HG explain next steps including follow up and goals/expectations for the next interaction? FD PD ND
- PD: Please use if the HG missed providing an accurate time frame for follow up and/or if the member does not have our mobile app and only did one of the following: Explained the value of the app Sent/offered to send the member a registration link
- ND: Please use when a plan was not provided when follow up is required and/or if the member is not enrolled in our app and we did not explain the value and also did not offer/send the member a registration link
- Knowledgeable and Confident:
- Knowledgeable and Confident 5 Points: Did the HG demonstrated Healthcare knowledge and display confident language? FD PD ND
- FD Anticipates issues before they arise, provides clear and confident guidance without reliance on others, drives faster and frictionless member outcomes.
- PD Correct but sometimes incomplete guidance, reactive rather than proactive support, inconsistent clarity when explaining to members.
- ND Frequent errors or unclear direction, high dependency on others for support, missed opportunities to resolve members needs.
- Wrapped Record 5 points:
- Wrapped Record 5 points: Must wrap the record in InView after every member interaction. FD ND