Access & Verify
What are the 3 pieces of the eligibility triangle?
Member Info
Group Info
Family Coverage
What is a short definition of a processed claim?
Medication was successfully ran at pharmacy
What is an NDC number?
Manufacture code
Why is it important to use today's date when running a coverage check?
It will give you up to date results
What is the 9th piece of patient info you can use to verify an account?
Social Security Number
Please do your introduction.
Thank you for calling. My name is _________, a Prior Authorization Representative. May I please have the patient's Member ID?
If there is no claim present for the requested medication, where do I search?
Drug coverage search under benefits
What is a single source medication
Medication has no generic form
Where are the 2 preferred places to access coverage check?
Drug coverage notes, claim details
What is a short definition of a caregiver?
Person who is put on account who can speak and act for patient
What are the 3 pieces of caller information we need for each call?
First name, first initial of last name, title
What is a 70 rejection?
Medication is not covered by plan
What must be present to create a PA?
A phone number
If the days supply is over 30 days, what pharmacy should I use?
ESI Mail Order Pharmacy
What must I ask a caller before accepting a transfer?
Has the caller been HIPAA verified and the account authenticated
What are the 8 pieces of patient information we can use to verify an account
Member ID, Name, DOB, Address, Zip Code, Phone Number, Case ID, Rx Number
What button do I click on in Claim Summary to get to the Claim Details?
Rx number
When will you use the HICL?
You don't.
If I run a coverage check and get a 88 rejection, what teams can overcome this?
Pharmacy Help Desk
What are 3 examples of PII?
Name, DOB, Address, Zip code, SSN
Search, alternate ID
Why should I always put more than 3 letters in a drug search
The more letters I put the less results I get
What color will a specialty medication be highlighted in under prospective pricing?
Yellow
Why is it important to run a coverage check after a PA is approved?
To see if filling pharmacy can process a claim
If the patient's plan covers a maximum of 4 tablets a day, and the patient needs 450/90, is an authorization required?
Yes, the plan would only cover 360