US · guidance
CMS Pub. 100-09, ch. 6, § 30.5
Inquiry Triage Process
MACs shall use a triage system to route general telephone inquiries to the most appropriate resource.
This tiered approach ensures inquiries are handled by staff with the right expertise, minimizing transfers
and improving efficiency. The system matches inquiry complexity with appropriate expertise, optimizing
both provider satisfaction and operational efficiency.
MAC’s may also use a similar approach to triage general written inquiries. MACs shall develop
mechanisms to quickly identify complex or sensitive written inquiries needing referral to the PRRS.
The figure below illustrates the levels of complexity and the corresponding provider inquiry volume.
Each MAC shall organize its dedicated provider telephone CSRs into at least two levels:
• First-level telephone CSRs, at a minimum, answer a wide range of basic questions that
self-service options can’t address. These representatives
o Answer inquiries that don’t require substantial research and can easily be
answered during the initial call
o Have the authority to refer more complex questions to second-level telephone
CSRs
• Second-level CSRs have more experience and expertise and may:
o Answer more complex questions requiring a higher level of research
o Serve as consultant subject matter experts for first-level CSRs without always
speaking directly to a provider
o Answer first-level CSR questions when workload demands
o Handle callbacks
CSRs shall refer the most complex questions or sensitive issues to the PRRS, as discussed in section
30.9.
MACs can enhance their provider inquiry triage systems by specializing their telephone CSRs within
skillset or across multiple PCC locations. This specialization allows MACs to leverage skills-based
routing, ensuring that provider inquiries reach the most appropriately skilled staff. Additionally, MACs
can implement technology solutions that automatically route callers based on the nature and complexity
of their inquiry, improving efficiency and first-call resolution rates.
For workload reporting purposes, if a call transfers between telephone CSR levels, the inquiry shall
remain open until it’s fully resolved and shall only be counted once.
Figure
History
(Rev. 13683; Issued: 04-08-26; Effective: 05-08-26; Implementation: 05-08-26)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
4bb2c426ceea1fa89259c745a6a09024abe1042025d23065a484a208177e2c22
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