Prior Authorizations
Adjudication
Workflow
Best Practices
Counseling / Training
Misc.
100
What is the system we send MOST of our PA's through?
Cover My Meds.
100
When running and eligibility check what is one piece of information that Enterprise does not always add?
Zip Code
100
What are the 4 pieces of information we need to add an insurance?
BIN, PCN, Group, ID
100
When your day supply is 12.5 what is the day supply you Data Enter?
12
100
After Counting a Warfarin script and the bottle is empty what do you do with it?
Throw it in the P-Listed waste bin.
200
How many days do we try for a PA?
7 days
200
Where do you go to check if a patient has a deductible?
Click "Claim Detail">"Response Pricing"> scroll down.
200
If a Patient has multiple scripts, another person picking up for them, has difficulty getting to the store, ETC. what is one service we can offer them?
Home Delivery, Mail Order, Instacart
200
What do you do with the RMA for IPLEDGE?
Add it in the "coupon number" field in Additional Information
200
If something rejects from Central Fill what do you do in data?
Hit the "Dispense order locally" button.
300
If a script is going through no-fault or COMP how do we start the PA?
Call the phone number listed.
300
If this script is a non-control what is our next step?
Click on the "Manage Claims" and adjust your DISPENSE QUANTITY AND day supply to 30 days or under based on the medication.
300
What is the company goal for accuracy and where can you find your weekly percentage?
93% and can be found in 1010 or posted in the department
300
If a patient wants a MES report sent through the mail what do you do?
Use the 1010 DATA forms link on the homepage and fill out the MES request form.
400
If a script falls back into workflow within a few minutes of auto-resubmitting a PA where should we look?
Check to see the script status with the CMM info button.
400
When we get a rejection stating, "prescriber not enrolled in Medicaid", what do we do?
Go to LexisNexis and search for the MD, if it states "Student in Organized health" you can place the student override in Additional Information. If the MD is not a student or is not a NY prescriber the script will have to be written by an MD that is enrolled in Medicaid, or they will have to pay through a discount card.
400
When you're on Release to Patient what are 4 things you should be confirming with EVERY transaction
Pt name, Address, DOB, # of scripts.
400
Double Jeopardy!
Intern End of Module Assessment
where is it located?
Sharepoint --> Online Forms --> Training --> Intern End of Module Assessment
400
Double Jeopardy!
If a patient on Medicare part D comes in and their copay is over $500 what is one solution you can offer them?
Hint: Adjudication will trigger this rejection.
M3P
What does M3P stand for?
500
After 7 days what should we do with a PA?
Check the "info" button, run the claim for that date of service, text the PT unsuccessful, and profile script
500
What is this rejection saying?
The script is not covered by INS at the retail level - The patient has to use Mail Order
500
Double Jeopardy!
When you receive a HIPAA form what do you do with it?
You put it in an intercompany mail envelope and send it to the Legal department.
What forms do we scan in store and where?
500
What is the process of filling CGM through ADS
Obtain consent either in person or verbal and scan the form into ERx
Resubmit claim using new third-party BIN:
o Third Party Name: ADS CGM Plan
o BIN 016466 and PCN ADS
o Patients 10-digit phone number in Cardholder ID field
Form can be found:
SharePoint --> Pharmacy Medicare and Medicaid Documents
500
What are the times we set things for in workflow?
4 AM - Specific NDC
1 PM - Refill too soon
3 PM - FOA
X:33 PM - RPH issue
9 PM - Patient or insurance issue
10 PM - Prior Authorization.
600
What information is needed for a vacation override?
Date they are leaving, Where they are going, How long they will be gone for, and if they are leaving the country.
As much information as possible!
600
If you see this rejection in the response message what are your next steps?
Option 1) See if the patient has paid this before Option 2) contact the patient, and send to update status for 3 days out
600
Double Jeopardy!
If a script is in sold status and we need to adjust the billing what process do we use?
BAR
What does BAR stand for?
If its a $0 refund do you need a form?
600
When giving a vaccine what 4 things must be included when introducing yourself to the patient?
Name, Title, Training, and vaccine being administered (ask them which vaccine they are here for)
600
Double Jeopardy!
A script for Zolpidem 10 MG adjudicates for a refill too soon for 3/15 and the RX has an earliest fill date of 3/16 what text message would you send?
"Refill too soon"
What do you do after you text the patient?