A
In Novartis EVA calls, are we allowed to use free text when the agent does not understand the question being asked?
No
Are you calling from the provider's office? or are you calling on behalf of the Doctor?
I am calling from Novartis Patient Support on behalf of the patient. I have consent from both the patient and the provider to obtain benefits information.
If the agent mentions the generic drug is covered, can we take it?
No
For Novartis bridge,
If the agent is unable to locate the member using the patient name, DOB, and ID, do we need to provide any other piece of info before submitting the call as unable to locate the member?
Yes, we need to provide the patients' zip code
If an agent says there is a Denied PA on file, which is 2 years old, do we need to collect that PA information?
Yes/No
Yes, we will still collect that Denied PA on file even if it's 2 years old
Op- " What is the prior auth turn around time?"
Agent- Anything that indicates agent doesn't know or have the information
In this case, should we headset that field or should we input 3-5 days?
We will not input 3-5 days, we will headset the question.
What is your job title?
I am a Coverage and Access specialist.
OP- Was an appeal submitted for Cosentyx?
Agent- I don't have information, or I don't know.
For this scenario, can we headset the question?
No, we will input Not on file
If the agent says PA denied, and the Appeal is overturned, what do we need to do in those cases?
We will mark PA on file as approved and will collect remianing question.
Note: Appeal overturned means there is an approved Appeal on file.
If the drug goes through medical, what do we do in those cases?
We will ask the agent name and reference, then we will GE the call and submit as all good.
If the agent says the drug is covered with an Appeal, do we need to ask anything else or are we just good to GE and submit the call?
We will mark the drug covered as No and will skip all the open questions, then we will GE the call and submit as all good.
If the agent says PA denied and there is an Appeal on file, do we still select that question as denied, or do we need to select PA on file and collect Appeal info?
We will select PA on file and will collect info for Appeal on file.
OP- Does this PA cover both the initial loading dose and the ongoing monthly maintenance dosing?
Agent- Only for the initial treatment or Only for ongoing treatment.
What will we input in this scenario?
We will input "No"
If there is a denied PA on file and Appeal is upheld / merged, in those cases, what we need to do?
We need to mark the Appeal on file as denied.
After marking "Payer Refuses to Release Benefits to Third Party: YES." if the agent can provide the opening 5 questions? Do we need to submit the call for fail as TPA?
No, If agent CAN provide any piece of information, we will submit the call as All Good.
What task note needs to be added if the agent says that the medication is covered with a new-to-market form?
The Task note will be "Medication name is a new drug pending formulary review. A new to market form needs to be submitted."
After marking "Payer Refuses to Release Benefits to Third Party: YES." if the agent can not provide the opening 5 questions? Do we need to submit the call for fail as TPA or All Good?
If the agent fails to provide all the 5 question answer, we will submit the call as TPA
OP- Which dosing type is the authorization approved for?
Agent- I don't know
OP- The loading dose is 1 dose per week for the first 28 days; the maintenance doses are 1 dose per every 28 days thereafter.
Agent- I don't know.
For this scenario, can we headset the question or do we need to GE the call and try again?
We will headset the question
Even after pushback, if agent fails to answer the question "Does this PA cover both the initial loading dose and the ongoing monthly maintenance dosing?"
Do we headset the question? or do we need to GE the call and submit?
We will "headset" the question.
For third-party refusals, what pushback do we need to use?
We have a signed consent from the patient authorizing us to verify benefits on their behalf. Would you accept this consent from our program start form or HIPAAconsent.com?
For Novartis human call, if the agent asks us, " Are you a drug manufacturer?
First Pushback: “I am calling from Novartis Patient Support on behalf of the patient. I have consent from both the patient and provider to obtain benefits information.”
Second Pushback: Novartis is the manufacturer of the medication and Novartis Patient Support is part of Novartis.
For human calls, if agent asks, What is Novartis?
Pb with- Novartis is the manufacturer of the medication and Novartis Patient Support is part of Novartis.
OP- Which dosing type is the authorization approved for?
Agent- I don't have information. I don't know.
For this scenario, what pushback will we use?
The loading dose is 1 dose per week for the first 28 days; the maintenance doses are 1 dose per every 28 days thereafter.
OP- Does this PA cover both the initial loading dose and the ongoing monthly maintenance dosing?
Agent- I don't know. I don't have information.
What pushback will we use in this scenario?
The loading dose is 1 dose per week for the first 28 days; the maintenance doses are 1 dose per every 28 days thereafter.
OP- Is the medication covered?
Agent- Needs a coverage review/coverage determination
what are the next steps if we encounter this situation?
We will mark Drug
Coverage: No.
Covered with PA: No.
FE Required: Yes.
Then we will ask remaining questions and GE