All Things Pharmacy

Direct Member Reimbursement Overview

100

Name at least one example on why a member may request a DMR.

• Pharmacy can't process the claim electronically.
• Member didn't have their Humana ID/CarePlus card.
• The member paid out of pocket and is seeking reimbursement.
• (see mentor for more answers)

200

 Members who receive treatment as an outpatient in an emergency room or outpatient facility must file this for Part D medications given during their stay.

Direct Member Reimbursement (DMR)

300

• The pharmacy DMR claim form may be referred to in different variations of:

•  Pharmacy DMR claim form
•  Drug claim form
•  Prescription drug claim form
•  DMR form

400

When a vaccine is administered here, proof of payment isn't required with the submission of the DMR form. 

A Doctor's office

500

 The Centers for Medicare & Medicaid Services require that members are given how many months from the date of the prescription fill to submit their claim for reimbursement.

36 months

Pharmacy Claims Overview

100

Advocated get calls about prescription drugs filled at the pharmacy from the following people 

Pharmacists and pharmacist technicians or Members and others on behalf of the member

200

These systems can be used to determine the coverage stage 

RxNova Call Connect

Mentor does advise RxConnect Pro but would not advise as it's not up to date like RxNova Call Connect.

300

This is the primary system used for claims research and resolve claims issues. 

RxNova Call Connect

400

This is the process document you would use to handle a non-clinical override.

Non-Clinical Override Call Types

500

What is the BIN and PCN for a MA only plan?

Bank ID Number: 610649

Process Control Number: 03200004

Pharmacy Verification of Benefits Overview

100

Members can switch their prescriptions to lower-cost alternatives such as these to save money

Generic Drugs

200

These type of benefits include any Part D benefits above and beyond the Centers for Medicare & Medicaid Services (CMS) standard Part D benefit. 

Enhanced benefits

300

This tool can be used for drug pricing for Group Medicare advocates.

RxConnect Pro

400

Inbound Rx VOB calls don't require you to give this, per compliance

A benefit disclaimer

500

 Members with limited income and resources can possibly qualify for this program, depending on their eligibility through the Social Security Administration. 

Extra Help Program

Actions for RxNova Error Codes

100

Also known as Error Code 082

Pre-authorization required

200

The error code for: Claim in Error - RTS

080

300

The definition for error code 177 

Use Appropriate Tab or Cap Strength for Dose

400

Error code for: Submit Claim to Primary payer 

090

500

Error Code for: Exceeds Quantity Therapy Allowed 

151