PA Status
This is the status when medication will not be covered by the insurance.
What is denied?
This is the PB used when the agent is asking for the provider's state when collecting the claims address.
This person initiates the prior authorization.
Who is the provider?
This pushback is required if the agent provides a PA that is Future dated, Expired, Denied or Pending.
What is "Is there an active one?"
This is the PB used when we are asking if claims are handled by the plan or if a TPA or Repricer is involved and the agent says "I don't understand".
Type of approval may need to be provided by a payor before acquiring a medication or treatment.
What is a prior authorization?
This pushback is required if pre-determination is not required and not highly recommended.
What is "Is pre-determination available?"
This is the next step when the agent cannot provide the timely filing period for claims submission.
What is headset?
If an agent offers to start the prior authorization process, this is the only appropriate response.
What is "By the way, I am not initiating a prior auth; just inquiring about the submission process or status, if applicable"?
The PA is cancelled and there is no active PA on file. This is the proper way to enter that data on the platform.
What is "Not on file?"
This PB is required as soon as the agent mentions the plan is handled by a dedicated department and they will need to transfer the call.
What is "Could I have the direct phone number for the dedicated team?" to include the direct number in the required TN.
Agent tells us that they have initiated an authorization and it is now going to review. This is our immediate next step.
What is prompt "Just a moment please" and immediately notify lead.
This is a formal review of a member’s requested medical care compared to their insurance’s medical and reimbursement policies. (Not an approval or denial)
What is Predetermination?
This is the PB required when the agent asks "what type of claim will you be submitting?" when asking for the claims address.
What is "What address can the provider send CMS-1500 claims to?"
This pushback is required when we are told that a PA is required and member's plan is a secondary plan.
What is "Is that true when the plan we're calling on is secondary?