Client Contact Form Page 2
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2*PRESCRIPTION DRUG ASSISTANCE
Medicare Advantage (HMO, PPO, SNP):
Eligibility/Screening
Medicare Prescription Drug Coverage (Part D):
Benefit Explanation
Eligibility/Screening
Plans Comparison
Benefit Explanation
Plan Enrollment/Disenrollment
Plans Comparison
Claims/Billing
Plan Enrollment/Disenrollment
Appeals/Grievances
Claims/Billing
Fraud and Abuse
Appeals/Grievances
Marketing/Sales Complaints or Issues
Fraud and Abuse
Quality of Care
Marketing/Sales Complaints or Issues
Plan Non-Renewal
Quality of Care
Plan Non-Renewal
Medicare Supplement/Medigap:
Eligibility/Screening
Part D Low Income Subsidy (LIS/Extra Help)
Benefit Explanation
Eligibility/Screening
Plans Comparison
Benefit Explanation
Plan Enrollment/Disenrollment
Application Assistance
Claims/Billing
Claims/Billing
Appeals/Grievances
Appeals/Grievances
Fraud and Abuse
Marketing/Sales Complaints or Issues
Other Prescription Assistance:
Quality of Care
Union/Employer Plan
Plan Non-Renewal
Military Drug Benefits/VETERANS
Manufacturer Programs
Medicaid:
State Pharmaceutical Assistance Program
Medicare Savings Program (MSP) Screening (QMB, SLMB, QI-1)
Other: ___________________
MSP Application Assistance
Medicaid (MH, SSI, LTC, FEW, Health Safety Net) Screening
Medicare (Parts A & B)
Medicaid Application Assistance
Eligibility
Medicaid/QMB Claims
Benefit Explanation
Fraud and Abuse
Claims/Billing
Appeals/Grievances
Other:
Fraud and Abuse
Long Term Care (LTC) Insurance
Quality of Care
LTC Partnership
LTC Other
Military Health Benefits/VETERANS Health Care
Employer/Federal Employee Health Benefits (FEHB)
COBRA
Other Health Insurance
Other: ___________________
*Total Time Spent on this Contact Date:
*Status (Select One Only):
General Information and Referral
Detailed Assistance – In Progress
Hours
Minutes
Detailed Assistance – Fully Completed
Problem Solving/Problem Resolution – In Progress
Problem Solving/Problem Resolution – Fully Complete
CMS Special Use Fields:
Potential Financial Assistance Provided:
______________________________________
MIPPA: 1 – LIS 2 – MSP 3 - Both
Applied for MassHealth Standard
______________________________________
Applied for LTC Medicaid/FEW
One Care:
Applied for MH Buy-in (QMB, SLMB, QI-1)
Dual Ref In Srce
1 2 3 4 5 6 7
______________________________________
Applied for Health Safety Net
Enrol Broker Asst
Y N
Applied for CommonHealth
Letter Stat Mcaid
Y N
______________________________________
Applied for Extra Help (LIS)
Managed Care Optn Y N
Enrollment Assist
Y N
Applied for Prescription Advantage
______________________________________
Y N
Other Mcare Issue
New to Medicare – MAPD or Part D Plan
Pubs Other Mater
Y N
Plan Search/Plan Change
______________________________________
Dual Refer Out
1 2 3 4 5 6 7 8
Switched Medigap from Sup 2 to Sup 1
Bene Disposition
1 2 3 4 5
______________________________________
Refer to VSO/Veteran of Vet? Y N
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