Scenarios
What macro would you select if a member called in to check on the status of their CP?
You'd take ownership of the CP and select the "Member IB" macro. You'd also add a note to Admin.
After 2 attempts to the pharmacy (Pharm Attempt-Unable to reach), what would be the next step?
You will call the PBM to see if there's a claim for the new medication. Please run the macro "PBM".
When do I use Pharm #Extra Attempt macro?
After MDO #Extra Attempt. This is typically only for High Priority CPs.
You get routed a CP that has Pharm #1-No new rx and Member OB: Emailed member to register for mail order. What is your next step?
You will proceed with MDO #1. The Member OB email to register does not effect your workflow.
After 2 "MDO Attempt-Unable to Reach", what is the next step?
You will contact the member for updated MDO info. Then, you will run the macro "Canceled-Doctor Unreachable".
If a receptionist puts you on hold at the MDO for 11 minutes, what macro would you run?
MDO Attempt-Unable to Reach.
If the MD is out of the office for 2 weeks, what would be your next step?
Macro: MDO out of office. Then, contact member to see if there's another PCP we can contact or tell them to reach out when the MD is back.
When is it appropriate to run the macro "Pharm #1-Complete" or "Pharm #2-Complete"?
When you speak with the new pharmacy and verify the new drug is received and verify the copay.
What macro would you run if you call the MDO and they verify there's no member with the name and DOB you've provided?
MDO #1-Wrong Provider
If you're working on a High Priority CP that's already had the Pharm#2-No new rx macro ran, what would you do next?
MDO #Extra Attempt (Verbal or LVM).
When would you use "NEW" macro?
Started a request from New status. (Missing doctor info or no fax - had to leave message)
When you call the pharmacy, they confirm the new Rx is received but it can't be filled for another month. What macro would you select?
(38) PHARM - Refill Too Soon > Contact member> Complete
If you confirm the pharmacy has received the new prescription but it requires a Prior Authorization, how would you proceed?
You would Select "(45) Rx Requires PA", contact the member to let them know the pharmacy will contact their MD and complete the CP.
What would be your next steps if you follow up with the MDO on a CP and the MDO tells you the member isn't taking the requested medication anymore?
Run the macro "(68) Member No Longer Taking Med" and cancel the CP.
Which macro would you run if the MDO denied the request due to the member being stable on their current medication?
(63) Denied - Member Stable on Current Medication > Contact member> Cancel