Vendor Audit Letter Template (Page 3 of 6) in pdf

4. Provider Termination and Appeal policy and procedures

5. If Accredited, copy of certification (i.e. URAC, NCQA or JCAHO)

CUSTOMER SERVICE

The following information is needed for the Customer Service Audit:

1. Member Service Call Log Reports

a. Indicate if (Name) has dedicated line for calls

b. Include detail for both mainstream member services number as well as

TTY/TDD.

2. Member Services Policies and Procedures (including call triage process,

TTY/TDD call handling and call scripts)

3. Abandonment Rate Reports

4. Manuals specific to assisting the Member Service Representatives

5. All Manuals and/or pamphlets that are provided to (Name) members

6. Policies and Procedures on Member Service Quality (i.e. – agents monitoring &

observation) as well as any materials currently being used to perform quality on

their agents.

7. Evidence of periodic testing of TTY/TDD numbers to ensure lines are working

properly (should be done on a monthly basis)

8. Current Training materials, including policies and procedures, for new agent

employee training as well as any follow-up training (including call training

modules)

9. Complaints taken by Member Service Representatives

10. Copies of fraud issues/concerns along with the outcomes taken by the Member

Services department

11. Information regarding retraining provided to new hires and/or member services

representatives due to performance deficiencies

12. Template of measurements, weights, and competencies for your quality tool

13. Language capabilities

PROVIDER RELATIONS/NETWORK DEVELOPMENT

The following information is needed for the Provider Relations/Network Development

Audit:

1. The process for selecting participating providers, including written policies and

procedures used for review and approval of providers

2. Process of identifying network gaps

3. Site visit Policy and Procedures

QUALITY MANAGEMENT

The following information is needed for the Quality Management Audit:

Vendor Audit Letter Template Page 3