PSS
What case information is considered Data Entry and therefore would NOT be considered a Provider Supporting Statement?
Tretinoin gel 0.01% with a dx of molluscum contagiosum for plan code 10026- NY CHP
REVIEW- per QRG molluscum contagiosum is not considered a cosmetic indication
Tolling and NAI are apart of what process?
Request For Information (RFI)
What resource would you use when checking for OHI?
Primary-Secondary COB Process
Where do you go to find formulary status of Medicare medications?
Formulary Search Tool (FST)
When is a PSS NOT required for an Exception case?
*Must List All
• Excluded Medications
• Tier requests (when medication is on an ineligible tier)
• Benefit Denials (Member was not eligible on the requested dates of service, PAP denials, etc.)
• Member/member representative (AOR/ POA) submitted request with enough information to approve without needing PSS
• Request Reason is Safety Edit 925 Only
• Case is being denied for “Non-Medically accepted indication” and is submitted by the provider
UZEDY Suspension Prefilled Syringe for plan code 11936--NY Medicaid - Essential Plan
REVIEW! While this is NF and non-self administered it is an exception to the exclusion for being an antipsychotic medication.
What are the following when routing a case to the RFI queue for additional outreach attempts
Additional Info Requested: Yes
Additional Info Received: BLANK
Status: In Progress
Status Reason: Additional Information Required
What resources are used to verify if NDCs are excluded for Medicare?
NSDE and MDP files
Who do you email when a case needs to be reassigned either to VHS or another technician?
WFM_Rx_Intraday@CENTENE.COM
Complete the following when a medication is requested for a non-medically accepted indication
External Template 2:
External Template 2: Not Part D Drug; CMS Chapter 6
Tretinoin Cream 0.05% with dx of acanthosis nigricans for plan code 10026 NY CHP
EXCLUDED!! 10026 Acanthosis nigricans is considered a cosmetic indication therefore is excluded under SSA
What is the RFI compliance Time rule?
For Monday-Sunday - Any case that is missing information that is due before 12PM Eastern Standard Time the next day and you are working the case after 4PM Eastern Standard time, a decision will need to be made after the provider outreach.
Where do you go to verify where to send a nebulizer solution?
BvD SA
What is something that should be included in every case that you work?
Internal Notes should include technician recommendations
What counts as a valid Provider Supporting Statements (PSS)?
Name at least 4 examples
The provider submits clinical notes
• The provider submits labs
• The provider indicates previously tried medications. This includes if the provider indicates that "no" medications have been previously tried on a fax or Questionnaire.
• Any reason why certain drugs cannot be used • This includes checking any boxes on the request form stating that the alternate drugs cannot be used and/or the patient • is stable on the current medication
• The provider indicates that the drug is medically necessary
• The provider indicates that the medication is a continuation of therapy
• The provider checks “Yes” or “No” on the RFI letter
• The provider gives ANY reason why the member requires the requested medication
• The provider indicates “yes” or “no” to HRM/Hospice
• For a Quantity Limit review, if the provider includes directions for use including titration schedule it can be considered a PSS.
NDC 49735011467/PHLEXY-10 Packet NY EP for plan code 11894?
REVIEW! While this is a NF OTC request- this is an exception to the rule as this is a PKU product.
You receive a case back from RFI that was NAI'd but should have been tolled and now has 4hrs left. What are the next steps for outreach and How should radio buttons be set up?
Update the case to toll using the time the initial outreach was made. **This can take place even if the case has less than 8 hours remaining.
1. Additional Info Required: No
2. Supporting statement received w/original request: No
3. Supporting info Requested: Yes
4. Update the Supporting Info Requested time to reflect the time of the initial phone call attempt shown in the Contacts tab
What document has backdate requirements for HIM or Medicaid plans?
Quick Reference Guide (QRG)
What should you do if you receive a customer service case that shows requested by AOR with no AOR on file?
Double Points!! Where did you find this information?
If there is no valid AOR on file updated requested by to Member request.
Double Points: Found in WellCare Sharepoint
True or False?
Member generated case with enough Information to approve
Supporting Stmt Received w/ Original Request radio button will: YES
False. The Supporting Stmt Received w/ Original Request radio button will NEVER be YES for Member/Third Party requests
NDC 37867050105 for NY CHP plan code 10026
REVIEW! Incontinence/diapers supplies are an exception to NF OTC exclusion.
You receive a member exception case. No clinical information received from member and no previous cases worked.
Outreach has been made (unsuccessful)
Case was NAI'd, PSS received
Additional Information still required
What process is being used and what are your radio buttons
Setup the case to route to NAI
1. Supporting Info Requested: Yes
2. Supporting Info Received: Yes
3. Supporting Info Received Date: Enter the date/time of the phone call where the supporting statement was received
*This should match the Time of Contact for the phone call documented in the Contacts tab
4. Additional Info Required: Yes
5. Additional Info Requested: Yes
6. Additional Info Received: Blank
Where do you go to find information if you have a 621/620 rejection?
Dual Plan Process SA
Where can you go to find team specific announcements?
NE Region SharePoint