MEM Standards & Guidelines
Standards for Member Connections (MEM)

1.    Health Risk Appraisals (MEM 1)
 
  • Does the plan provide a health risk appraisal that can allow members to assess their risk of morbidity and mortality and identify ways the risks can be reduced?
  • Does the plan provide resources that can assist members in reducing risks?
  • Is the HRA available on the Web and in an alternative format?
2.    Interactive Consumer Health Tool (MEM 2)

  • Does the plan provide Web-based interactive tools to assist members in reducing risk of major health problems?
  • Are the tools reviewed and kept current?
  • Are the tools tested for usefulness and understanding?
3.    Functionality of Claims Processing (MEM 3)

  • Does the plan have Web and telephone capability to allow members to obtain information on their claims?
  • Does the plan measure whether the claims are handled in a timely and accurate way?
4.    Pharmacy Benefit (MEM 4)

  • Are members able to query information about their pharmacy benefits, financial responsibility for medication and pharmacy operations on the Web and by telephone?
  • Does the plan have a process to ensure the pharmacy information is accurate and current?
5.    Personalized Information on Health Plan Services (MEM 5)

  • Are members able to request or reorder an ID card or change a primary care practitioner on the Web?
  • Can members determine how and when to obtain referrals and benefit responsibility for services over the Web or by telephone?
  • Does the plan ensure the accuracy of the benefit information it communicates?
  • Does the plan assess member satisfaction of its member materials and the help they get through customer services over the telephone?
6.    Innovations in Member Service (MEM 6)

  • Does the plan encourage the use of technology to improve services, convenience and appropriate use of health benefits?
7.    Health Information Line (MEM 7)

  • Can members access a health information line to receive answers to health related inquiries?
  • Is the Health Information Line available 24 hours a day by telephone?
  • Does Health Information Line provide staff with the ability to follow up on cases and link members’ contacts with a contact history?
  • Does the plan track members’ use of the Health Information Line?
8.    Encouraging Wellness and Prevention (MEM 8)

  • Does the plan identify members who are eligible for wellness programs?
  • Does the plan provide follow-up to members based on member specific information?
  • Does the plan offer incentives to members for taking action on wellness and prevention?
9.    Delegation of MEM (MEM 9)

  • If the plan delegates member connections activities to a third party, is the decision-making process—including the responsibilities of the plan and delegated party—clearly documented?
  • Does the plan evaluate and approve the delegated party’s ability to perform these services beforehand, and on a regular basis?



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