Data Entry
True or False:
Agent states they do not know info for the PBM; we can headset.
TRUE-after PB
True or false. If Plan is secondary to Medicare and the agent states "we follow medicare guidelines" for PA requirements we Select No.
TRUE
Agent checks the network status, then confirms it's only covered for emergencies. How do we proceed?
Take whatever network status the agent gives. GE the call and obtain agent name and reference number. No need to collect benefits if it's only for emergencies.
Mark J code not valid and billable.
Mark no infusion benefits.
Line 62
True or False: we must PB "is there an active one?" when the agent tells us the policy is terminated.
FALSE
If plan is terminated, we do NOT need to collect PBM info. Line 44
If agent advises " For Jcode, there will be a $40 copay", what is the correct response?
And coinsurance?
Optum Infusion is Out Of Network, there are No OON benefits, and agent will not provide In-Network benefits; which task note is required?
This plan has no out of network benefits.
True or False: If the agent states they can not see the diagnosis code on the PA, we should input Approved with different diagnosis code and continue with follow up questions.
FALSE Mark as approved.
Line 333
If the agent advises that the provider is OON and the member has OON benefits, what benefits are we to collect?
INN & OON
What PB is needed if PBM and Specialty pharmacy are the same?
Just to confirm, the pharmacy benefits manager and specialty pharmacy are the same, is that correct?
Line 164
When asking " what is the copay or coinsurance for a specialist office visit?" and the agent responds " There will be a $15 copay with member being responsible for 40%", what do you input?
$15 copay
Agent states "The patient can get their specialty medication at any specialty pharmacy, but the preferred pharamcy is Accredo." Which should be entered? -Open Network or Accredo?
Accredo
What do we do when the agent states the Prior authorization for the admin code is handled by a different department than for the Jcode?
Collect department name and phone number. Use task note for the administration code information.
BCBS Agent advises " I cannot check if your are participating, you need to contact your provider", how do we proceed?
Prompt " According to the BCBS website, I am showing that the provider is listed, may we please proceed with INN benefits? (Do not check website for BCBS)
When asking "In the Home Health Setting, is the drug admin covered?" the agent responds "I don't know". What PB must we use?
Can you check that please?
Line 297
True or False: When asking for Jcode copay or coinsurance, the agent responds with " For the Jcode, there will be a 25% coinsurance when billed with the specialist office visit", it is ok to input 25% for Jcode.
FALSE
The patient is the daughter of the policy holder: which is the correct entry?
- Self
- Dependent
- Spouse
Dependent
If the agent states Prior authorization is not required, we are okay to skip the question "do you see a prior auth on file?"
FALSE. We still must ask the PA on file question.
Agent advised " Out of Network Benefits are only available with an approved Prior Authorization", how do we proceed?
Continue call and collect OON benefits
TRUE OR FALSE: When an agent asks if we are in network with the local, we need to PB with "can you check that please?".
FALSE
Line 76
When asking for the copay or coinsurance for either the SOV, Jcode or Admin code, the agent says " It will be between 15%-45%", how will we input this?
45% (always take the higher amount)
Agent states the Specialty pharmacy is BriovaRx; what is the correct data entry?
A.CVS Specialty Pharmacy
B.CarelonRx
C.Optum Specialty Pharmacy
C.Optum Specialty Pharmacy
If the agent is unable to see a provider listed on the PA, what is the appropriate PB?
Can any provider use this prior authorization?
Line 329
TRUE OR FALSE: If Optum is OON and the patient does not have OON benefits, we should GE.
FALSE
We should still try to collect INN.
Line 67
Agent states there is NO PBM for this plan. What PB must we prompt?
Is there a 3rd party that administers the prescription drug benefits for this plan?
Line 161
For Humana only, when asking for the Jcode copay or coinsurance, the agent advises " We no longer quote part B drugs, you need to check the fee schedule", what should we do in this situation?
Mark Jcode as valid and billable and headset copay and coinsurance.