Form Approved
OMB Number 0935-0118
Expiration Date 01/31/2013

MEDICAL PHARMACY COMPONENT FOR REFERENCE YEAR 2010

CONTACT GUIDE FOR PHARMACIES

VERSION 1.0

MEDICAL PHARMACY COMPONENT FOR REFERENCE YEAR 2010

CONTACT GUIDE FOR PHARMACIES

SECTION A:  CALL PROVIDER

A1. [1] (READ IF NOT OBVIOUS: (Hello,) Have I reached (PHARMACY NAME)?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR), OR SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.

• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE PHARMACY. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE PHARMACY.

• IF NO BETTER NUMBER IS AVAILABLE, SELECT "NO" BELOW.

  YES ... = 1 (GO TO A2)
  NO ... = 2 (GO TO EXIT SCREEN)

A2. [2]  I have (an) authorization form(s) for the release of patient profiles and would like to speak to the pharmacist.

• IF THE PHARMACIST IS UNAVAILABLE ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

• IF RECORDS ARE KEPT BY A DIFFERENT DEPARTMENT OR CORPORATE OFFICE, ASK TO SPEAK WITH THE PERSON IN THE PHARMACY WHO DEALS WITH THE OTHER DEPARTMENT OR CORPORATE OFFICE.

CONTINUE = 1 (GO TO B1)
NO OTHER DEPARTMENT; NOT CLEAR WHO TO SPEAK TO = 2 (GO TO EXIT SCREEN)

SECTION B:  IDENTIFY DC POC

B1. [3] (READ IF NECESSARY: Hello, my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of patient profiles and would like to speak to the pharmacist.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON,
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PERSON IS ON THE PHONE......................... 1 (GO TO B2)
PERSON IS NOT AVAILABLE / CALL BACK.......................... 2 (GO TO APPOINTMENT SCREEN)

B2. [3] At this time, [NUMBER] of your customers identified (PHARMACY NAME) as a place where they received prescribed medication during 2010. (The/Each) patient signed an authorization form allowing us to contact you for information about the prescribed medication they received from (PHARMACY NAME) in 2010. Much of the information we need is within the patient profiles. Are the patient profiles maintained in your office, in another department or your corporate office?

• IF ASKED CLICK HERE FOR CUSTOMER NAMES AND OTHER IDENTIFYING INFORMATION

• IF THE PERSON ON THE PHONE IS NOT SURE, ASK TO SPEAK WITH/BE TRANSFERRED TO SOMEONE WHO WOULD KNOW ABOUT THE PATIENT PROFILES FROM 2010 AND RESTART THIS SECTION. -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PHARMACY MAINTAINS THE INFORMATION .........................= 1 (GO TO B2b)
NEED TO CONTACT CORPORATE/OTHER DEPARTMENT FOR AUTHORIZATION..........=2 (GO TO B2_1)

B2_1. Are you the person who deals with the (other department/corporate office)?

YES = 1 (go to C2)
NO = 2 (go to B2a)

B2a.  I"ll need to collect the name and telephone number for the person in your office who deals with (your corporate office/the other department).

PRESS "NEXT" TO GO TO THE CONTACT BLOCK.

[GO TO CONTACT BLOCK]

B2b.  [4]   I would like to fax the authorization form[s] to you, along with additional information explaining the study. I need to be sure I have the correct information for the packet. Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:
  1. PROVIDE THE DATA,
  2. JUST NEEDS A COURTESY PACKET, OR,
  3. HAS TO GIVE PERMISSION.
  
  
• IF ASKED, CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.
  
  
• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.
  
  
• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.
  • IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION.
  • IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION.
  
  
• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

YES .............. = 1
NO ............... = 2

[GO TO CONTACT BLOCK]

B3.  Can you please provide the name and number for the person who needs to receive the courtesy packet/needs to receive the forms to approve the release of data?

• IF PERSON ON PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK, THEN GO TO SECTION F: DC: EXPLAIN NEXT STEPS.

• IF PERSON ON PHONE SAYS NO, YOU WILL BE TAKEN TO THE EXIT SCREEN. BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPEVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

YES .......... = 1 (GO TO CONTACT BLOCK).
NO ........... = 2 (GO TO EXIT SCREEN ).

SECTION C:  IDENTIFY OTHER DEPT./CORP. 

C1.  (READ IF NECESSARY: Hello, my name is (YOUR NAME).)

I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of patient profiles and would like to speak to the person that can help me get in touch with (the department who maintains patient profiles/your corporate office).)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON, AND RESTART THIS SECTION -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PERSON IS ON THE PHONE ..... = 1 (GO TO C2).
PERSON IS NOT AVAILABLE/CALL BACK ... = 2 (GO TO SET APPOINTMENT SCREEN).

C2.  (READ IF NECESSARY: At this time, [NUMBER FROM CUSTOMER LIST] customer[s] identified [PHARMACY] as a place that they received prescribed medication during 2010. [The/Each] customer signed an authorization form allowing us to contact you for information about the prescribed medication they received from [PHARMACY] in 2010.)

We should be able to get all of the information we need from (the other department/your corporate office).
We can also fax you a copy of the authorization form[s] for your files.

I need to be sure I have the correct information for the packet. Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE:
1. DEALS WITH THE EXTERNAL BILLING SERVICE,
2. JUST NEEDS A COURTESY PACKET, OR,
3. HAS TO GIVE PERMISSION.
   
   
• IF ASKED READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.
  
  
• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.
  
  
• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.
• IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION.
• IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION.
• IF ADDING A COURTESY PERMISSION PACKET RECIPIENT, ADD OR EDIT BOTH POCS TO THE CONTACT BLOCK.
  
  
• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S)]: In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

YES ...................... = 1
NO ....................... = 2

[GO TO CONTACT BLOCK]

C3.  Can you please provide the name and telephone number of the person at (the other department/your corporate office) that I need to contact?

• IF PERSON ON THE PHONE SAYS YES, ADD THE NEW PERSON TO THE CONTACT BLOCK, THEN EXIT AND CALL THE OTHER DEPARTMENT/CORPORATE OFFICE.

• IF PERSON ON PHONE SAYS NO, ASK TO SPEAK WITH SOMEONE WHO CAN PROVIDE THIS INFORMATION AND RESTART THIS SECTION. IF NO ONE CAN, EXIT AND BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

YES ....................... = 1 (GO TO CONTACT BLOCK).
NO ........................ = 2 (GO TO EXIT SCREEN).

SECTION D:  CALL OTHER DEPT./CORP.

D1.  (READ IF NOT OBVIOUS: (Hello) Have I reached [OTHER DEPARTMENT/CORPORATE OFFICE]?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR), -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.

• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE OTHER DEPARTMENT/CORPORATE OFFICE. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE OTHER DEPARTMENT/CORPORATE OFFICE.

• IF NO BETTER NUMBER IS AVAILABLE, SELECT "NO" BELOW.

YES ........................ = 1 (GO TO D2)
NO ......................... = 2 (GO TO EXIT)

D2.  (Hello,) I have [an] authorization form[s] for the release of patient profiles and would like to speak to the person that can help me with that process.

(READ IF NECESSARY: We are interested in collecting profiles for each customer that includes the amount paid by the customer and the amount paid by any third party payers for all prescriptions in 2010. We are also interested in collecting the NDC, date filled or refilled, and quantity dispensed with dosage form. We would appreciate it if you could also include the types of the third parties.)

IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLE ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

CONTINUE = 1 (GO TO E1)

DEPT./CORP. OFC. DOES NOT MAINTAIN 2010 PROFILES FOR PHARMACY = 2 (GO TO EXIT SCREEN)

NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3 (GO TO EXIT SCREEN)

SECTION E:  OTHER DEPT./CORP.: IDENTIFY POC

E1.  (READ IF NECESSARY: Hello, my name is (YOUR NAME).)

I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of patient profiles and would like to speak to the person that can help me with that process.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON AND RESTART THIS SECTION, -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PERSON IS ON THE PHONE.........................= 1 (GO TO E2)
PERSON IS NOT AVAILABLE/CALL BACK....................= 2 (GO TO APPOINTMENT SCREEN)

E2. (READ IF NECESSARY: At this time, [NUMBER FROM CUSTOMER LIST] customer[s] identified [PHARMACY] as a place where they received prescribed medication during 2010. [The/Each] customer signed an authorization form allowing us to contact you for information about the prescribed medication they received from [PHARMACY] in 2010.)

I would like to fax the authorization form[s] to you, along with additional information explaining the study.

I need to be sure I have the correct information for the packet. Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:
1. PROVIDE THE DATA,
2. JUST NEEDS A COURTESY PACKET, OR
3. HAS TO GIVE PERMISSION
   
   
• IF ASKED READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.
  
  
• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.
  
  
• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.
• IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION
• IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION
  
  
• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

YES ........................ = 1
NO .......................... = 2

[GO TO CONTACT BLOCK]

E3.  Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs to receive the forms) to approve the release of data?

YES ....................... = 1 (GO TO CONTACT BLOCK).
NO ........................ = 2 (GO TO EXIT SCREEN ).

• IF PERSON ON PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK SECTION. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK, THEN GO TO SECTION F: DC: EXPLAIN NEXT STEPS.
  
  
• IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.
  
  

SECTION F:  DC:  EXPLAIN NEXT STEPS

F1.  [6] Once you have received the authorization form(s), (and permission to release data to us has been given to you,) [if # of customers is < or =25, show "we will call back to collect the data over the phone", if # of customers is >25, show "you can send us the patient profiles by either fax or mail, or we can call back to collect the data over the phone."]  We are interested in collecting profiles for each customer that includes the amount paid by the customer and the amount paid by any third party payers for all prescriptions in 2010. We are also interested in collecting the NDC, date filled or refilled, and quantity dispensed with dosage form. We would appreciate it if you could also include the types of the third parties.

(In order for permission to be granted, we will send the authorization forms as a part of a study packet.)

IF THE PERSON ON THE PHONE EXPRESSES A CONCERN ABOUT PROVIDING DATA OVER THE PHONE, SAY "You can also send us the patient profiles by either fax or mail. "

PHARMACY WILL RESPOND:

BY PHONE ..................................................... 1(GO TO F2)
BY FAX ........................................................... 2(GO TO F3)
BY MAIL ......................................................... 3(GO TO F3)

F2.  Within the next 24 hours we will [fax/mail] you the authorization form[s] and include an instruction sheet. If you have any questions about the information we will need, please call our toll-free number on the instruction sheet. We will allow time for you to receive and review the authorization form[s], and then we will call you back to verify that you have received the form[s]. When we call back, we'll also work with you to set up a good time to collect the data over the phone (once you've received permission to release the data).

We may call again if other customers identify this pharmacy as a source of prescribed medication.

[GO TO EXIT SCREEN].

F3.  Within the next 24 hours we will [fax/mail] you the authorization form[s] and include an instruction sheet. If you have any questions about what to send us, please call our toll-free number on the instruction sheet. We will call you back to verify that you have received the form[s]. We hope you can send the patient profiles to our office within two weeks.

We may call again if other customers identify this pharmacy as a source of prescribed medication.

YOU WILL NOW BE TAKEN TO THE EXIT SCREEN AND THEN TO THE CMS.

[GO TO EXIT SCREEN].

SECTION G:  VERIFY RECEIPT OF AFS

G_Intro.  [9]  May I please speak to (POC)?

PERSON IS ON THE PHONE.........................= 1 (GO TO G1)
PERSON IS NOT AVAILABLE........................= 2 (GO TO APPOINTMENT SCREEN)

G1.  [9]  (Hello, my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study. (We've confirmed that the authorization form[s] we sent in order to receive permission for the release of information [has/have] been received.)

Did you receive the authorization form(s) we (faxed/mailed)?

YES, RECEIVED ALL .................1 (GO TO G2 IF MODE = PHONE; GO TO G4 IF MODE = FAX/MAIL)

YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND ...................2 (GO TO G5)

NO ...................3 (GO TO G5)

G2.  [14/15]  If it is convenient for you, we can just go ahead and complete the data forms together over the phone right now. I'd be happy to hold on while you get the information you need from your records.

WILL COMPLETE BY PHONE NOW.................................. 1 (GO TO EXIT SCREEN)
WILL COMPLETE BY PHONE IN THE FUTURE............... 2 (GO TO G3)

IF THE POC WANTS TO COMPLETE BY PHONE NOW, YOU WILL EXIT THE CONTACT GUIDE AND RETURN TO CMS. CODE THE CASE AS "AUTHORIZATION FORMS RECEIVED - READY FOR PHONE DATA COLLECTION". THEN, PROCEED TO THE PATIENT LISTING SCREEN TO BEGIN EVENT FORM DATA COLLECTION.

G3.  [16] I understand. What would be the best day and time to call you back to complete the data forms?

• PROBE FOR THE BEST DATE AND TIME.
  
  
• IF THE PERSON ON THE PHONE IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:
  -ASK WHICH DAY OF THE WEEK IS BEST
  -ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:
• EARLY MORNING = 9AM
• LATE MORNING = 11AM
• EARLY AFTERNOON = 2PM
• LATE AFTERNOON = 4PM
  
  

DATE: ______
TIME (HRS/MINS): ________
TIME ZONE: _____

[GO TO EXIT SCREEN]

G4.  [N/A]  Our records indicate that you will (fax/mail) the records to us. We hope you can do so within two weeks.

[GO TO EXIT SCREEN]

G5.  I'm sorry. Let me re-send the authorization form(s) to you.

I need to be sure I have the correct information for the packet. Should I direct it to you?

YES = 1
NO = 2

• IF ASKED CLICK HERE FOR CUSTOMER NAMES AND OTHER IDENTIFYING INFORMATION.

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S):
  Inorder to reamin HIPAA compliant, I need to send you the authorizationi forms first. Once you have received the forms, then we can arrange for the collection of the data.

• CLICK NEXT TO PROCEED TO THE CONTACT BLOCK AND ENTER OR EDIT CONTACT INFORMATION FOR THE POC WHO SHOULD RECEIVE THE PACKET. THEN EXIT THE CONTACT GUIDE AND CODE THE CASE IN CMS.

[GO TO CONTACT BLOCK]

SECTION H:  BAD INFO. FOR OTHER DEPT./CORP.

H1.  ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE
This is (YOUR NAME)calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for (OTHER DEPARTMENT / CORPORATE). Unfortunately we were unable to locate (OTHER DEPARTMENT / CORPORATE) with the contact information you provided. Could you please verify the contact information we currently have for (OTHER DEPARTMENT / CORPORATE)?

PERSONS NAME:_______________________________

TITLE: _____________________________________

NAME OF DEPARTMENT/OFFICE:__________________

TELEPHONE (_____)___________ EXT:___________

OTHER DEPT./CORP. OFFICE CONTACT INFO IS CORRECT =1 (GO TO H2)
OTHER DEPT./CORP. OFFICE CONTACT INFO IS NOT CORRECT =2 (GO TO CONTACT BLOCK)

H2.  That is currently the information we have on file. Do you know of any other way we can get in touch with [CORPORATE / DEPARTMENT NAME]?

YES = 1 (GO TO CONTACT BLOCK)
NO = 2 (GO TO EXIT SCREEN)

IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION I:  OTHER DEPT./CORP. CONTACT?

I1.  ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE OTHER DEPARTMENT OR CORPORATE OFFICE
This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for (OTHER DEPARTMENT / CORPORATE). We were able to locate (OTHER DEPARTMENT / CORPORATE) with the information you provided. However, they reported that they did not maintain the patient profiles for (PHARMACY NAME) in 2010. Could you please check to see if another department maintained profiles for (PHARMACY NAME) in 2010?

OTHER BILLING SERVICE MAINTAINED RECORDS ............ 1 (GO TO CONTACT BLOCK)
NO OTHER BILLING SERVICE MAINTAINED RECORDS............ 2 (GO TO EXIT SCREEN)

IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS CASE REQUIRES SUPERVISOR REVIEW AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION J:  GAINING PERMISSION

INTRODUCTION:

May I please speak to [POC NAME]?

Hello, my name is (YOUR NAME).
I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

I recently spoke with (POC YOU ARE WORKING WITH FOR DATA COLLECTION) about the study. I explained that at this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PHARMACY] as a place where they received prescribed medication during 2010. [The/Each] patient signed an authorization form allowing us to contact you for information about the prescribed medication they received from [PHARMACY] in 2010. Much of the information we need is within the patient profiles.

(POC YOU ARE WORKING WITH FOR DATA COLLECTION) has agreed to participate and provide us with the information we are looking for, but has requested that we first send you a copy of the authorization form[s] for patients in order to receive permission to release the data to us.

Im calling to confirm that you are in fact the best person to receive the form[s] and information about the study by fax, and confirm your contact information so that I can address the fax to you.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON AND RESTART THIS SECTION,
  -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THAT PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK.

• PRESS NEXT TO CONTINUE TO THE CONTACT BLOCK.

[GO TO CONTACT BLOCK]

VERIFY PERMISSION PACKET RECEIPT:

May I please speak to [POC NAME]?

(Hello, my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. We previously spoke about the MEPS study. For quality assurance this call may be monitored. Did you receive the authorization form[s] we sent to you?

• IF THE PERSON ON THE PHONE DID RECEIVE THE FORMS, ASK:
  
  
• Do you have any questions or concerns about the study information or the forms we sent?
  
  
• At this point may I follow-up with (POC YOU ARE WORKING WITH FOR DATA COLLECTION) about the release of data?
  
  
• IF YOU ARE CLEARED TO SPEAK WITH THE POC YOU ARE WORKING WITH FOR DATA COLLECTION,
  
  
• EXIT TO THE CMS, MAKE THE POC YOU ARE WORKING WITH FOR DATA COLLECTION THE PRIMARY POC ON THE POC SCREEN
  
  
• CALL THEM USING SECTION G: VERIFY RECEIPT OF AFs
  
  
• IF THE PERSON ON THE PHONE DOES NOT GIVE YOU PERMISSION
  
  
• EXIT TO THE CMS TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS
  
  
• IF THE PERSON ON THE PHONE DID NOT RECEIVE THE FORMS, SAY:
  
  
• I'm sorry. Let me re-send the authorization form[s] to you.
  
  
• GO TO THE CONTACT BLOCK BY PRESSING NEXT AND VERIFY THE CONTACT INFORMATION WE HAVE ON FILE, THEN
  
  
• EXIT TO THE CMS AND TRIGGER A RE-SEND OF THE PERMISSION PACKET TO THIS PERSON
  
  
[GO TO CONTACT BLOCK]

CONTACT BLOCK

IF YOU ARE BEING REFERRED TO A NEW POC BY SOMEONE ELSE, COLLECT ONLY NAME AND PHONE NUMBER.

IF YOU WOULD LIKE TO EDIT OR VERIFY INFORMATION FOR A POC YOU HAVE ALREADY COLLECTED INFORMATION FOR, CLICK "EDIT" NEXT TO THEIR NAME IN THE TABLE ABOVE.

IF UPDATING OR VERIFYING A POC FOR SENDING A MAIL/FAX PACKET TRY TO COLLECT/ VERIFY ALL FIELDS.

IF GIVEN INFORMATION FOR SOMEONE OTHER THAN THE PERSON ON THE PHONE, ALWAYS ASK TO BE TRANSFERRED TO THAT PERSON.

CONTACT FIELDS

PHARMACY NAME:
OTHER DEPARTMENT/CORPORATE OFFICE NAME:
POC FIRST NAME:
POC LAST NAME:
PHONE:
EXT:
FAX:
VERIFY FAX:
TITLE:
DEPARTMENT:
ADDRESS:
CITY:
STATE:
ZIP:

FOLLOW-UP QUESTiONS

CB1. WORK WITH THIS POC ON THE NEXT STEP/CALL?

1. YES
2. NO

CB2. WHAT TYPE OF POC DID YOU ENTER INFORMATION FOR?

1. PHARMACY LEVEL GATEKEEPER
2. HANDLES RELEASE OF IN-HOUSE PROFILES
3. DEALS WITH OTHER DEPARTMENT/CORPORATE OFFICE
4. OTHER DEPARTMENT/CORPORATE OFFICE GATEKEEPER
5. HANDLES RELEASE OF RECORDS FOR OTHER DEPARTMENT/CORPORATE OFFICE
6. COURTESY PACKET RECIPIENT
7. PERMISSION PACKET RECIPIENT

CB3. WHAT TYPE OF PACKET ARE YOU SENDING?

IF THE PERSON ON THE PHONE DID NOT EXPRESS A CONCERN ABOUT RECEIVING A FAX, SAY:
" To confirm, I will be sending the authorization forms by fax."

IF THE PERSON ON THE PHONE DID EXPRESS A CONCERN ABOUT RECEIVING A FAX, SAY:
" To confirm, I will be sending the authorization forms by mail."

1. FAX
2. MAIL

CB4. ADD ANTOHER POC?

1. YES
2. NO

SET CALLBACK/APPOINTMENT

Can you please provide me with a better time to call back in order to reach him/her?

• PROBE FOR THE BEST DATE AND TIME.
  
  
• IF THE PERSON ON THE PHONE IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:

-ASK WHICH DAY OF THE WEEK IS BEST
-ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:

• EARLY MORNING = 9AM
• LATE MORNING = 11AM
• EARLY AFTERNOON = 2PM
• LATE AFTERNOON = 4PM

DATE:
TIME (HRS / MINS):
TIME ZONE:

EXIT SCREEN

PRESS "FINISH" TO EXIT THE CONTACT GUIDE AND ENTER THE CASE MANAGEMENT SYSTEM.
DO NOT HANG UP UNTIL YOU REACH THE CALL DISPOSITION SCREEN.

• IF A PERMISSION PACKET MUST BE SENT, YOU MUST DO THE FOLLOWING:
1. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR RECORDS FIRST.
2. MAKE A FOLLOW-UP CALL TO THE POC WHO WILL GRANT PERMISSION, USING SECTION J: GAINING PERMISSION.
   
   
• IF A COURTESY PACKET MUST BE SENT, YOU MUST DO THE FOLLOWING:
1. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR THE COURTESY PACKET FIRST.
2. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR RECORDS.

PROVIDER VERIFICATION SCREEN

Before we send you the authorization form(s), I'll need to determine that all of the providers I have listed were in fact associated with this practice during 2010. I'm going to read you a list of providers, and for each one, please tell me if each one was associated with this practice in 2010.

IF A PROVIDER IS NOT ASSOCIATED WITH THIS PRACTICE IN 2010, CHECK THE BOX NEXT TO THEIR NAME. IF NO PROVIDERS ARE REMOVED FROM THE LIST, YOU MUST STILL CLICK SAVE BELOW.