Part B Medications
What is no. They are Dual Status, not QMB Eligible. (Found in WI CarelonRx Senior Team: QMB Part B Process Content ID: 064461)
If a member repeatedly calls about 7x issues, you open this task
What is an SRT Inquiry Task
f the Alternate Ins Flag field displays “N,” the account is set up as this type of coverage
What is Primary
When contacting PSL, you must document these two details in your notes.
: What are the PSL agent’s name and US Domain
For accumulation issues, you review this tab in PeopleSafe for reversals at retail
What is the Account Balance tab
A member with x8406 GRS MAPD is calling because her FREESTYLE LIBRE 3 SENSORS have $250 dollar copay despite her having LIS Level 3. You check Marx and member qualifies for QMB code 01. What Member IDs are required before calling the pharmacy to attempt a resolution of processing?
What are the Medicare Member ID and Medicaid Member ID! (Answer is found in the CarelonRx Senior Team: QMB Part B Process Content ID: 064461)
This Windows tool helps calculate backstock based on fill dates and day supply
What is the Date Calculation feature in Calculator
Part D plans must update their systems within this timeframe after receiving BAE documentation
What is 72 hours
For Standalone plans, you should never contact PSL. Instead, refer to this resource first.
What is the CIF (Client Information File)
For eligibility issues where the member is not found in RxClaim, you refer to this work instruction
What is CarelonRx Senior Team – Real Time Resolution of Eligibility Issues
A member with x8415 INDV MAPD is calling to check on the status of their ALBUTEROL 2.5MG/3ML (0.083%) INH SOLN Coverage Determination. A test claim results in Reject A6. You check the View PA tab and notice the notes of the PA mention that it's been transferred to Part B authorization benefits team for approval. How do you proceed with educating the member on the PA status?
Since the Prior Authorization has been transferred to the Part B authorization benefits team, we would educate the member on where their medication is pending coverage and warm transfer to Member Services to determine the, now Medical, Part B authorization and further coverage/copay questions member may have for their Part B benefits.
If a member filled a 90-day supply but refilled after 56 days, this is their backstock
What is 34 pills
For Standalone plans, if LIS doesn’t match, what task should be submitted
What is a Senior Inquiry Task for a SalesForce case
If POA/AOR forms were confirmed by MMS but not loaded into PeopleSafe after 72 hours, you contact this team
What is PSL
If a member needs a letter translated and Customer Care cannot provide it, you refer to this work instruction
What is CarelonRx Written Translation to Alternate Languages
A pharmacy is calling for help with a member under x8412 INDV MAPD, who is trying to receive a TT Vaccine for tetanus. They're having trouble processing the vaccine under the Part D benefits. What probing questions do you need to ask to determine if this should be ran under Part D benefits? What work instruction helps you determine how this should be ran? (Optional Bonus Question worth 200 points: How does the pharmacy run Part D benefits? How do they run Part B benefits?)
You should ask probing questions on if this is solely preventative or if member had an accidental puncture word, which would lead the claim to be processed under Part B benefits since it is considered a medical event. The WI is CarelonRx Medicare Vaccines Content ID: 022844 (Bonus Question answer: Part D is ran with Member ID, BIN, PCN, GRP. Part B is ran with MBI ID only.)
For Standalone Plans, you contact this team before entering an override
What is AM through Senior Inquiry Task
If a member has less than 14 days of medication and LIS doesn’t match, who should the Senior contact
Who is Pharmacy Second Level Services
his state limits C2 controlled substances to a 30-day supply, even if the plan approves more
What is New Jersey
For general assistance with compound calls, refer to this work instruction
What is CarelonRx Handling Compound Calls – Care
A member with x8404 GRS MAPD is calling because their TADALIFIL is giving a $17 dollar copay. The member has LIS Level 2, there is an approved PA on file. You check Marx and verify the member is QMB Eligible code 02, however PeopleSafe Financials are not showing the claim hitting Part C or QMB benefits. Should the QMB process still be followed? How can you explain this copay to the member and what steps should you take to resolve this issue?
Using the CIF, the keyword 'Tadalafil' will explain that although the drug used to be part of the Extra Covered Drug program, a program for OTC medications to receive a small portion of coverage from the plan without truly being covered, the medication should now be paying per Part D benefits. You should call PSL to resolve the benefit error occurring so that Tadalafil will pay according to the member's Part D LIS benefits.
Before entering a 7x override for Medicaid accounts, this is required if the medication is a controlled substance
What is client permission
To verify if the group is still active, you place the cursor over this field and press F4
What is Group number
This reject code indicates a lockout for specialty retail pharmacy
What is Reject R6
This program restricts Medicaid members to a single pharmacy or prescriber
What is CarelonRx Medicaid Pharmacy/Prescriber Lock-In Program