Quality Control Process

Transcription

1 Quality Control Process 1. Quality Control Process Setup/Testing/Validation Letters & Kits I. New/Revised Letters A. Newly/revised documents are received from Medicare Advantage Compliance for accuracy. B. BCBSM (MA) will add all MLE instructions for TGI to program all letters or forms. C. BCBSM (MA) will create a transmittal. D. Transmittal will be reviewed by TGI Project Manager and confirm all specifications are clear and understood. Confirm all open issues with BCBSM (MA). E. TGI Account Director or Project Manager will send quote associated to transmittal request. F. TGI Project Manager will route TGI work request(s) for processing through internal departmental areas. G. Detailed departmental work requests are reviewed and processed by qualified departmental associates. H. BCBSM (MA) will send a test MLE file to TGI for the new MLE letter type to ensure accuracy. I. TGI send an notification to BCBSM (MA Fulfillment) indicating a test proof is available for review through the FTP before moving to production. J. BCBSM (MA) will review test proof and will reply to TGI of appropriate actions: Revisions required or approved. If revisions are required, the process steps start over with item e through I. K. If test proof is approved by BCBSM (MA), TGI will provide a live production proof. L. BCBSM (MA) will review production proof and will reply to TGI of appropriate actions: Revisions required or approved. If revisions are required, the process steps start over with item e, skipping items g, h and I. M. If production proof is approved, TGI will move letter into production. N. BCBSM will close transmittal after request has been fulfilled.

2 II. Daily Letters A. MA Fulfillment random sampling of letters thru Ika from the daily MLE B. MA Fulfillment will verify for accuracy 1. Material ID 2. Logo 3. Contract Statement 4. Letter Sent Date 5. Appropriate Reason Code/Transaction Reply Codes 6. Product (EVSA, Opt A & Opt B and Group) 7. Dollar amounts if applicable 8. Various dates if applicable C. MA Fulfillment will contact TGI for any discrepancies with the MLE. III. ANOC/ARK ANOC for Group and Individual / ARK for Individual A. BCBSM to provide TGI master kit content instruction document. B. TGI will provide kit set up proofs of all kit contents without variable 1. BCBSM Individual fulfillment will review and approve for production a) Verify material ID b) 800 number c) Product type (EVS, Opt A & B) C. Individual Fulfillment will request membership data pull from (DMR) Data Management Request D. DMR gathers requested data 1. Peer review is conducted before final is sent to MA fulfillment. E. Individual Fulfillment random samples data file in Ika 1. Verifying product (EVSA, Opt A & Opt B) 2. Address 3. County F. Individual Fulfillment passes the membership file to TGI G. TGI will provide proofs for each product (EVSA, Opt A & Opt B) 1. Coversheet 10 of each product 2. LIS Rider letter of member s who are LIS eligible 10 of each product H. Individual Fulfillment will do an on site quality check at TGI for accuracy 1. Kit content verify material id 2. Coversheet verify membership product/address/county I. TGI to provide postage statement by 1. Product 2. Qty 3. Date sent

3 IV. Pre Enrollment/ANOC & ARK Group (ARK & ANOC are combined for one mailing) A. All Group ANOC s must be in member s hand by each year s established deadline. B. Group Fulfillment request membership data pull from DMR 1. Request MPSER/URMBT/City of Detroit in their own tab 2. MAPD in a separate tab 3. MA Only in a separate tab 4. PDP in a separate tab C. DMR gathers requested data 1. Peer review is conducted before final is sent to Group fulfillment D. Group Fulfillment random samples data file in Ika 1. Verifying product (EVSA, Opt A & Opt B) 2. Address 3. County E. Group Fulfillment passes membership file to TGI F. TGI will provide proofs for each tab/group ID 1. Coversheet 10 of each tab/group ID 2. LIS Rider letter of member s who are LIS eligible 10 of each tab/group ID This could at times equate to less than 10 as some groups are smaller than 10 G. Group Fulfillment will review and approve for production. H. Group Fulfillment will do a on site quality check at TGI for accuracy 1. Kit content verify material id 2. Coversheet verify membership product/address/county 2. Communication of errors/ issues during the setup process I. Hardcopy and/or PDF Proofs A. Initial proof to be provided by TGI from documents and/or test data supplied by BCBSM. B. Any errors found during proofing by BCBSM will be sent back to TGI with specific information to correct. C. TGI will send back revised proofs to BCBSM for approval. D. If proof is correct, BCBSM will review and give appropriate approval to TGI via .

4 II. Automated Processing Proofs and/or Reports A. IKA/MLE Files (Daily Kit and Letter) Requests: 1. Rejected records will be reviewed on the appropriate Hold report by BCBSM with appropriate action being taken internally based on whether error was triggered by a Processor or by Programming. 2. BCBSM will notify TGI via a transmittal of any discrepancies on their part found in the MLE or notify TGI via or phone if discrepancy appears to be coming from TGI s side. 3. TGI will provide pdf proof of correction to error/issue found to BCBSM via secure If further discussion to correct issue is required, BCBSM or TGI will initiate a meeting for expanded review. 5. Timetable to resolve rejects is within 24 hours of occurrence. B. Group Pre Enrollment and Group Welcome: 1. Rejected records will be reviewed on the Enrollment Hold report by TGI and findings communicated to BCBSM if immediate reason cannot be found and corrected by TGI. 2. If found to be a TGI process issue, TGI will reprocess the rejected records immediately, which will reflect in the next automated file processing notification to BCBSM. 3. If found to be a BCBSM issue, TGI will communicate with BCBSM the error found. Any corrections provided by BCSM are to be processed in the next business day s file. 4. TGI will reprocess and review the next Enrollment report which provides proof of correction to error/issue to BCBSM based on file name. 5. If further discussion to correct issue is required, BCBSM or TGI will initiate a meeting for expanded review. 6. Timetable to resolve rejects is within 24 hours of occurrence.

5 III. Disaster Recovery A. TGI loss of power or processing systems. 1. TGI will identify all affected projects/processes. 2. TGI will contact, via phone and with follow up (with availability), the lead contact for each project/process affected upon occurrence(s). 3. TGI will prepare and route all projects/processes in accordance with the TGI Disaster Recovery and Business Continuity Plan approved by BCBSM. B. BCBSM loss of power or processing systems. 1. BCBSM will contact TGI within 24 hours of loss of power or processing systems. 2. BCBSM will contact TGI within 24 hours of ika systems loss of power or processing systems. 3. BCBSM will notify TGI immediately after power has been restored. IV. Escalated Issues Tracking A. All issues, other than transmittal requests, will require monitoring through the existing Issue Log with progress tracked through the BCBSM/TGI weekly meetings. 3. Direct Dialog between BCBSM and TGI Programming/Project Management I. BCBSM will send a Transmittal to TGI Direct with the desired request. 1. TGI will acknowledge receipt and respond to BCBSM with any questions or requests for clarification within 1 business day. 2. BCBSM will acknowledge and respond to any questions from TGI regarding the Transmittal Request within 1 business day. II. Initial Project Fact Gathering Meeting 1. TGI will set up meeting with invitation to all required participants from appropriate Departments, along with the applicable Account and/or Project Managers, Analysts and Consultants. Required participants to be determined based on program type. 2. Meeting notes are to be captured by TGI Account or Project Manager.

6 III. Implement the Project Production Process 1. Specific TGI production department details will be captured in TGI s production request and tracking software, assigning desired testing, proof and completion dates and routed to required production departments. 2. If questions arise during TGI program development, Project Manager will notify BCBSM and request a conference call or meeting to obtain answers to the question and/or further review. 3. BCBSM will correct or modify any necessary changes for the request. And send back to TGI for implementation. 4. TGI Project manager will capture further requirements within the TGI production tracking software. 5. Once program development is complete, the Account and/or Project Manager will inform BCBSM when the development test or proof files are ready for review. 6. Upon test or proof approval from BCBSM, TGI will proceed to production phase and provide a first piece production proof. 7. Upon production proof approval from BCBSM, TGI will publish to live production. TGI Direct Inc. and Blue Cross Blue Shield of Michigan (BCBSM) agree to the business rules listed above for the Quality Control Process to be strictly followed by TGI Associates and BCBSM Employees working on this business. X Don Smith TGI DIRECT X Pete Thomas BCBSM 08/05/14 DATE 08/05/14 DATE