PRIOR AUTHORIZATION
The patient calls in to check status of a new prior authorization submitted by their prescriber. This is the path you take to locate the status of their Prior Authorization.
What is Benefits tab and then Coverage Review Status?
This phone icon sends the patient to the survey after the call.
Phone button with the "X"(End Call)
Caller states, "How much do I owe you"? You can find the patient's current balance, by using this path
What is the Accounts tabs and then Payments and Invoices?
A call comes in and the account populates. The authorization banner is green. The call came into the IVRU "authenticated". The caller is the patient. This information is still needed to continue the call.
What is the patients Full Name? (First and Last name displayed in CSP)
Patient calls in and states, "I ordered my medication 2 weeks ago. Can you check the status?" This screen is where you go to check the status of an order in process.
What is the Order Screen?
A medication needs a PA in order for us to fill it. This person is solely responsible for submitting a PA to Express Scripts for the patient's medication.
Who is the patient's prescriber or doctor?
This patient is out of medication.She/He may or may not be able to obtain a STS at a local pharmacy ( Ex. CVS or Walgreens). If accepted you would transfer the caller to this person to assist with clinical/medical questions about IOT (Interruption of Therapy).
What is a PC-RPH(Pharmacist)?
The amount of credit authorized by Express Scripts for members to order medications. Once reached a payment must be made to order additional medication going forward. Members must stay below this amount for medication to process.
What is the Floor Limit?
A daughter calls in for her mother and account populates. The banner is green. The call came in "authenticated" through the IVRU. This information is still needed to continue the call.
What is the patient's Full Name, the caller's Full Name and relationship to the patient?
Medication can become pended medication in our system for several reasons. Name at least 2 scenarios a medication would be on hold.
What is a PA(coverage review), Customer Service Pend, or Held For Fulfillment Issue (Multiple Issues), Information Needed, DUR (Drug Under Review)?
A PA can be submitted in 3 ways to "Held for Coverage Review" department aka Prior Authorization department.
What is electronically via Cover My Meds(CMM), Fax, or Phone Call?
Patient received 30 day supply, but expected a 90 day supply. Transfer to this person.
What is a PCT (Patient Care Technician)?
The amount the member authorizes Express Scripts to process on any order.
What is Authorization Limit?
Nurse from the prescriber's office is calling in for order status. After she gives the patient's name(call came in authenticated). You will also need this information.
What is First name and first letter of the last name, prescriber's NPI, and callback number?
In the event you cannot find an order status or medication processing, but caller says it should be. You can reach out to this person for additional assistance on the order.
Who is PCT (Patient Care Tech)?
CSP says the patients PA is approved, the Rx when searched displays an orange link "Coverage Review" and the medication is pended. Two departments are able to handle this call.
What is Customer Service (PCA) and Patient Care Technician (PCT)?
Conference 2 parties with this phone icon
What is the button with 2 phones?
What is the MTF (Base)?
What is Personal Representative(caregiver), Parent, or Patient?
less than 90 days, this can now be provided to the member since the order has not been delivered.
What is a replacement?
I only received 10 tablets, why can't I get more? The patient would need what placed on the account to attempt to resolve their issue.
What is a PLA (Patient Level Authorization)?
My Specialty medication was transferred to another pharmacy. These are handled by..
What is ACCREDO? (An Express Scripts Pharmacy)
Medication cost is based on which structure set by the member's plan?
What is a Medication Tier?
Other than the 3 P's. The caller authenticated and provided their name. They need the name and the (blank) of the medication to provide additional information.
What is the strength?
A medication has shown shipped for 33 days now, but less than 90 days, this can now be provided to the member since the order has not been delivered. Difference is this medication is temp sensitive. this person has to process this replacement for the member.
Who is PCRPH?(Pharmacist)