REJECTS
What internal error codes are eligible for an Admin Override
Reject A6, reject 6E, reject 41, Reject 620, Reject 76, & Reject 78
What tabs are you supposed to check when a caller is calling regarding a PA?
Prior Authorization Tab
Fax Tab
Web/IVR Transactions
Clinical Notes
How long is Prime's grace period for (1) following their start time or lunch break and (2) leaving early at the end of their scheduled shift.
A five (5) minute period of time is allowed to employees.
What is considered as a complaint?
When caller is expressing dissatisfaction with a
Medi-Cal Rx pharmacy benefit or its administration.
Examples:
Unhappy with the Medi-Cal Rx coverage policy
Unhappy with the quality of care, compliance, or timeliness of care
Inaccuracies or no coverage of services
Incorrect or insufficient information was provided
Unhappy with customer service such as rudeness or being mistreated by a provider or employee
What is needed to validate a Beneficiary when a Pharmacy or Provider Authenticated is calling?
The benefits identification card (BIC) ID (Cardholder ID in FirstTrax℠) OR the member’s full name.
The member’s date of birth
For Reject 78 what are the two overridable scenarios?
1) When there is an existing Approved PA on file
2) Claim for OTC Drug is for $100 or less
When does a contact detail need to be created?
On every call a contact detail needs to be created.
Where can you find information for Prime's Employee Assistance Program (EAP)?
Go to Prime Therapeutics > HR + You Website
Click on the Life Drop Down Menu
Choose Employee Assistance Program from the drop-down menu.
What are the ways to submit a Complaint or Grievance?
Mailed Correspondence
Phone
Email or Chat
Fax
Can the CSR proactively provide the caller with beneficiaries BIC ID Number?
No, the CSR should not proactively provide the BIC ID # to the caller. After a complete validation is provided by the beneficiary, provider, prescriber, or pharmacy the CSR may provide the BIC ID # to the caller upon request.
For Reject 76: plan limitations exceeded
Internal Error 2641: Metric decimal quantity exceeded per day limit.
1 Quantity per day limit applies to who?
Members who are NOT Pregnant
Members who do NOT take Insulin
What are some reasons to leave a contact detail In Progress?
Escalations
Complaint or Grievance
Crisis Call
After Independence Day, when is Prime's next designated paid holiday?
Labor Day Monday, September 2, 2024
Do agents have to select a CTI for a Complaint or Grievance?
No, it is not necessary to change the CTI or user location since the guided workflow will have already selected this.
The CTI will have
already been selected by the guided workflow.
For Beneficiaries, if the call comes through authenticated via the IVR Transfer Code field. The CSR must still verify the following piece of information?
The Member’s Full Name
Reject 6E - M/I Other Payer Reject Code
Internal Error 50075 - Error List M/I Other Payer Reject Code
In the COB Tab > Reject CD Field if Primary rejected claim for MR - Product Not on Formulary, can the CSR override this?
No. The rejection that the pharmacy receives from the primary insurance is not accepted by Medi-Cal Rx.
The Pharmacy will need to exhaust all options with Primary first. Where Alternatives tried, was a PA submitted with Primary?
After all attempts were made to process the coordination of benefits (COB), the customer service representative (CSR) should conduct an assessment for possible administrative override (ADM Override).
Where can you locate the price of the medication in FirstTrax?
Go to the claim
Select Pricing
Select Incoming
View the Gross Amount Due
if you have used all of your PTO, can you still apply Safe & Sick time?
You will NOT be able to use the Sick & Safe Time code, even though it may still accrue.
When caller is expressing dissatisfaction or presents an issue that qualifies as a complaint, but then says they don't want to file a complaint,
Are agents still obligated to take down the complaint?
Yes, we still need to make an attempt to advise the caller we are still required to file an anonymous complaint on their behalf and no letters will be sent.
For Pharmacy calling authenticated through the IVR, what is the scripting?
“I see you fully authenticated in the IVR. Can you confirm the name of the pharmacy you are calling from? Thank you, can you also provide the full name of the member you are calling about?”
For Internal Error: 50920 - Error List Pharm Not Enroll in State Medicaid Program
Reject 890 - Pharmacy Not Enrolled in State Medicaid Program
Which tool on DHCS website can CSRs find out whether the NPI Provided is active or not?
On DHCS website, search Ordering, Referring and Prescribing (ORP) | Medi-Cal Providers link.
What available fields can be used to narrow down a claim search?
Rx number, DOS, Auth #, Adj date, Days Prior, Claims Status
Unscheduled Absences accrue over an Attendance Year, when does it fall off or expire?
Unscheduled Absences “fall off” or “expire” one (1) year from the date incurred.
When filing a complaint, which color is the scripting that needs to be read to caller?
Read the BLUE scripted text aloud to the caller to make sure all required information has been provided
For callers that are the Parent of a Minor, if the call comes through authenticated via the IVR Transfer Code field. The CSR must still verify the following piece of information?
The CSR must still verify the following:
Member’s full name
Ask if they are the custodial parent:
− If no, PHI cannot be released.
− If yes, PHI can be released.