Status Reason
Your approving a Formulary medication with no UM the is within the Quality Limit. What would your status reason be?
Status Reason: Formulary-No Override
When running a test claim in MHK, you notice your claim rejection code/ messaging is 79- Refill too soon. What would be your request reason?
Formulary
You notice there is an active PA on file when you run your test claim in MHK and the mock pays? Your status would be (blank) and your status reason would be (blank).
Your status would be in progress and your status reason would be possible duplicate.
You received a request for Adderall XR 15mg capsule, quantity of 30 capsules for 30 days. The member is 4 years old.
What would your request reason be?
Age Limit
Dual Eligibility flag is “DUAL MEMBER” and there is Medicare and Medicaid spans. Would you work this case as normal or send the case to secondary?
Send this case to secondary if the case has NOT been evaluated by Secondary Review.
We received a request for Vyvanse 40mg capsules, quantity requested 120 capsules for 30 days.
Per Fab viewer you notice the plans daily dose restriction is 1 each daily.
What would your request reason be?
Quantity Limit
The medication you're viewing for is rejecting for NP, when viewing your Step Action, your status reason should be Admin-Denied Alternatives. True or False
False. Per SA 25 for HIM, SSHP & LAHC or SA 26 for core medicaid Medical Necessity Not Met should be your Status Reason.
When should the request reason be selected?
After Test Claim and checking the Formulary Status of the medication following Case Logic.
You received a request for LOB HIM-GA on 10/15/2022. Patient has previous denial on 08/04/2022. Would you send this medication to duplicate or would view this medication as a new request?
You would review the medication as a new request because the first attempt was made over 30 days ago.
The request reason should always match the status reason. (True or False)
False. The request reason should always match the test Claim and checking the Formulary Status of the medication following Case Logic.