This lists the parameters necessary to process a claim for a plan.
What is the processing information section (ribbon) of the benefits link?
100
Click on this to access the Claim Information page.
What is the Rx#?
100
Benefit Maximum, Deductible, MOOP
What are the accumulators for commercial plans?
100
Limitations on the coverage of medications
What is an edit?
100
Senior Vice President of Customer Service
Who is Mark Knutson?
200
Has five different tabs.
What is the Member Detail screen?
200
Once the correct customer is selected, this is the default tab displayed.
What is the Member Claim History?
200
This is the type of deductible that most of our external clients use.
What is an Embedded Deductible?
200
Where we find the DUR percentage.
What is the Processing Information section?
200
Director of OptumRx in Costa Mesa
Who is Lisa Jansen?
300
You would need to change this if a pharmacy receives a claim rejection indicating the claim should be submitted to the primary insurance carrier and the customer indicates (and you have verified) that none exist.
What is the Alternate insurance flag?
300
The same as a DAW code. Indicates if the patient or physician have specified brand only.
What is the Product Selection Code?
300
This accumulation is used to determine when a member moves from the Coverage Gap to Catastrophic Coverage.
What is TrOOP (True Out Of Pocket)?
300
The equation used to calculate the new day supply for a dosage change.
What is Original Quantity / New Directions?
300
Your supervisor
What is Minoj Jalota?
400
The message stating your results returned with a member/claim associated with an employee's account.
What is "Restricted Profile'?
400
Where you can see how many times the pharmacy has tried to process the claim.
What is the Claim Transmission History section?
400
Though the member pays this, it doesn not count towards the out of pocket.
What is a premium?
400
An example of this type of edit:
Prozac – Non-Formulary unless the member has a history of up to a 30-day supply in the last 180 days.
What is Step Therapy or Contingency edit?
400
A PBM administers the pharmacy benefit on behalf of the insurance plan, and assumes a more behind-the-scenes role.
What is Carved In benefit?
500
VCC
How do we access (as PHD advocates) RxHD?
500
This indicates another pharmacy has already processed the same prescription or the same pharmacy processed the same prescription but used a different prescription number or NDC number than the previous claim in the member’s claim history.
What is a DUR Reject Error?
500
Mbr has a copay for brand meds of $15. Their monthly benefit maximum is $300. They have filled 6 medications (retail cost $150 each). This is the member's responsibility on the 7th med this month.
What is 100% total cost of medication?
500
Displays RxHD data and data submitted by the pharmacy.
What is the Pharmacy Transmission Information Comparison page?
500
An organization that manages pharmaceutical benefits, formulary management, clinical review and cost containment for a managed care organizations such as employer groups, health plans, and labor unions.