Overview
Line of Business Must Match This in the Overview tab
What is the Plan Name
What is 10/5?
This many Participants must be added in order to move forward with building a case.
What is 2?
When a case is assigned to you, Assigned to Investigator activity is promoted, and is closed with this activity.
What is Case-Prepared for Initial Review?
When Client Audit Summary is received, this is the Financial Type selected.
What is Initial Overpayment Amount?
Case Phase must be updated to this when the investigator pursues investigation
What is Case-Preliminary Report
When a Medicare lead is received, we have this many days to open a case.
What is 14 days?
Participant is the Pharmacy. This is the Participant Role.
What is Primary Subject?
The follow-up activity for Case-Prepared for Initial Review is this.
What is "Complete Preliminary Investigation and obtain Manager approval"? *which may be modified to fit your case
When SIU receives recoveries report from Caremark/PBM, this date is entered as the effective date.
What is the date the report was received?
Investigation Type and Subject Type are these when investigating a foot bath prescriber.
What is Pharmacy and Provider?
Regarding a Caremark audit, the Start and End Date of Incident represent this.
What is the audit time frame?
If from Caremark, Reported By Participant Type is this.
What is "PBM"?
This activity should be selected when documenting a telephonic communication with a member.
What is Phone Call - Member?
SIU received recoveries for WC FL H1034, this Financial Plan LOB is selected.
What is Medicare?
Peachstate Ambetter, WC-Peachcare GKD, and NV Centurion Health Plan are these LOB's in this order.
What is Marketplace (commercial), Medicaid, and Correctional?
When a lead is received from Envolve Pharmacy Solutions or Caremark, this is selected as the Lead Source Type.
A prescriber is identified as an outlier within a pharmacy case. The prescriber is entered as this in the Participant Role.
What is Additional Subject?
This activity is used when a prescriber verification letter is sent.
What is Letter - Sent?
This is always selected as Financial Stage for pharmacy cases.
What is Post-Pay?
Initial Suspect Amount = this exposure
What is audit/review timeframe?
Caremark Medicaid notice is for Florida, and a case is opened on 01/15. The Client Audit Summary has findings for OH Medicare, sent on 4/15. This must be entered in the Leads tab to ensure CMS compliance in regards to lead received date.
What is "Date Medicare Was Identified" field?
Participant ID is the same as this for pharmacy cases.
What is NPI?
A Client Audit Summary is received. This activity is used to document PBM findings + additional analysis.
What is Investigative Audit Results Reviewed?
What is each discrepant claim listed on each Client Audit Summary?