Work Instruction
True or False? Scenario; You have a pending non-urgent appeal and new information is provided that now makes the appeal urgent.
Are you required to notify the RPH/LPN of additional information and that it is now urgent ?
TRUE
As of 02/06/25, what is accepted as a new Dx other than Weight loss?
Obstructive sleep apnea
You get a fax that was sent to us from PA. The time stamp on the cover reads: 02/10/2025 07:30 Z123456. What time zone is this in?
Arizona time, no time zone was specified.
You receive a medical necessity letter that states the patient is in severe pain.. What indicator is this?
URGENT Indicator
IN COMM PA When You see rejection: PA Required for coverage at In House Pharmacy Only. Drug Excluded at this location Route of Administration Not Covered Plan Exclusion (PHARMACY HELP DESK 1-800-238-6279) 70 - NDC/Product/Service Not Covered 70 18002386279
what do you do?
YOU CHECK YOUR RED MESSAGE TAB AND RUN IT WITH THE (NPI:1760424428)/ ncpdp: 3145097) GIVEN TO US TO GET THE REJECT 75.
True or False? In the medical necessity que you would open the pending appeal record and select the This PA is Urgent check box to set the Urgent flag. You would then Change the Request Recd Date to the received date on the new fax. Add PA Notes as presented or in a similar statement: “Upgrading to urgent per new fax received <date/time>.”
TRUE
True or False : Date of test is not required. We can accept AHI>15 on Polysomnography test even if chart notes do not specify date of test
True
March 9 is day light saving how many hours will you add to ONLY Arizona time zone earliest time stamp on a fax?
2 hours!
You receive an appeal request that says I urge you to approve this request is this considered urgent?
NO URGE AND URGENT ARE NOT THE SAME WORD.
Reject example: is this a exception or IBR ?? What are 2 ways to identify?
+ not covered_ use norethindrone .. check for Caremark aca coverage by replacing rea in member ID non covered plan exclusion non formulary drug contact prescriber 70 ndc not covered MR
Exception request! You would identify by checking your red message tab and most importantly your drug class drop down (EXCEPTIONS) to select the correct exceptions form
You receive an appeal request and after looking through the chart notes / medical necessity letter it is approvable. What would your notes look like?
Approve <drug name> x (xx) months. Criteria met. Initials, date. Include quantity if appropriate.
Select the approve close option.
True or False: We are not required to verify the strength of the medication and should answer the criteria as the MD/MDO suggest.
False: For Zepbound maintenance therapy it needs to be 10 mg or 15 mg strength for approval; any other strength will lead to a denial.
It is required to enter a completed received timestamp each time an appeal is to be closed. Which work instruction states this?
Locating and Converting Time Stamps
You receive an appeal request and check pa history you noticed that it was already approved in COMM pa but its rejecting for you.. what do you do?
You can either reach out to pa seniors (877-214-7231) to apply an override per guidelines or email them. PASenior.Rep@CVSHealth.com
Patient is 48 requesting Oxycodone what criteria form would you look for?
Maximum Daily Dose of 6.0000 (PHARMACY HELP DESK 1-800-238-6279) 76 - Plan Limitations Exceeded 76 18002386279
OPIOIDS IR 7 DAY APAP-ASA-IBU COMBO acute pain duration limit
You are pending a second level appeal what work instruction do you look at to determine what you should attach the fax as?
Content ID : CMS-PRD1-068034
First and Second Level Medical Necessity Appeals to the MNRO - Appeals Commercial
Yes or No:
We can approve the criteria if the pt is <18 years old
No, If the member is under 18yrs old we are to forward to the RPh or LPN for further review.
You have 2 time stamps one is on the envelope and one is on the bottom of the appeal request which is the correct time stamp to use?
The envelope
Scenario: You receive a request with really nothing for the rph/LPN to go off of example: no medication name no chart notes no LOMN... what do you do?
Use close option appeals COMM-need LOMN
For a compound rejection:
76 PLAN LIMITATIONS EXCEEDED PA REQUIRED, COMPOUND RX - MD CALL CVS CAREMARK 1-800-294-5979. PLAN LIMITATIONS EXCEEDED 70 NDC/PRODUCT/SERVICE NOT COVERED ING02PLAN EXCLUSION
There is no Exception available. Should a clinical PA be worked on compound criteria?
No. Only 75/76 rejects with 70 OTC not covered are worked as clinical.
After researching the request you determine an appeal is not needed, what is your next step?
a. The request should be faxed or mailed back from the Unassigned Queue
b. The request should be routed to the target queue.
What does HSAT stand for?
Home Sleep Apnea Test
You receive an incoming appeal request with a timestamp assigned by the Medicare database, MedHOK. What do you do?
It is the earliest time and will always be Central Time (CT). It is important that the timestamp recorded on fax coversheets as received in MedHOK are NOT converted.
Is verification needed if name is a derivation of the first name [such as: Matt/Matthew or Suzie/Suzan]?
NO
For reject 71/ client carefirst dc risk/ Prescriber is not covered "plan exclusion. coverage through noom. Contact plan for details at 833-556-3163 No override allowed
What criteria form would you use? Where would you find what criteria form to use?
Red message tab states WORK IBR USING CUSTOM IBR LABELED INITIAL BENIFIT REVIEW CAREFIRST-WEIGHTLOSS