Members/Physicians/Clients
Where is the client name located?
Member center main screen
A reconsideration of a pre-service claim denial that requires a review of clinical information about a member’s medical condition. LOMN (letter of medical necessity), lab notes, chart notes may need to be included.
Appeals
Where is the timestamp located?
Bottom left corner of fax
The second loop of the ePA process which includes when the physician has returned completed criteria for processing (Clinical Follow Up, Incomplete, and Pending Approval)
Loop 2
A pharmacy service that dispenses biotech medications (primarily injectable) to members with chronic or genetic conditions. The rejection may have R6 in the messaging phone number ends in 5506
Specialty (SGM/CRU)
Where is the PAG located
PA Details
PA is closed by a Pharmacist or Medical Director due to NOT meeting clinical criteria or providing insufficient information. Insufficient information is considered to be a clinical__________.
Denial
Where can we see prior claim information?
PA history
What does it mean when the Smart Routing tool advises you to: Verify Drug Name (Reselect the Drug Name, if Applicable)?
Select the correct drug name in the drop-down menu.
User must update the drug name from one of the available options in the dropdown menu. This ensures the correct macros are loaded.
How can you view the rejection?
Run a test claim in CAS
Is used to access plan design highlights or other client specific information needed to resolve the plan member’s inquiry. They are located in theSource using the level 1 code.
CIF (client information form)
List of approved or recommended drugs deemed to be the most effective and economical
Formulary
Where can you change the criteria form?
Change PA type/Drug class
If the doctor says the patient has lost 5% of body weight what documentation is needed to complete the PA?
Starting weight and date/ current weight and date
Weight prior to therapy:__________ Date:_____
Weight after drug therapy:________ Date:_____
A resource available for Pharmacy Technicians and Pharmacists containing information such as work instructions, job aids, announcements, policies, procedures and client information
the Source
If we are searching by NPI or Fax in CAS, who are we trying to verify?
Physician
Activities and actions completed by the computer system or fax server.
This document should be opened first to verify member name, DOB, drug. It may contain criteria questions and chart notes. Where is it located?
Attachments/Communications tab
What does it mean when Smart Routing advises you to: Validate a PA is Needed?
Perform the following:
Glycated hemoglobin – an ____ test will identify the patient’s average plasma glucose concentration over the past 2 to 3 months. Chart notes are usually needed to answer the criteria question
A1c
What must you do to the member first and last name to search for the profile?
Wildcard ( J* Smit*)
Mock processing of a prescription used to verify benefit coverage, co-pay, and sometimes pricing for a specific drug, for a specific member. When a _____ ________ is performed, the prescription and coverage information is processed according to the individual member’s plan design and prescription history.
Test claim
When multiple timestamps are present, the _____ appropriate timestamp must be used.
Earliest
If fax is received with clinical information, Request Received timestamp will then be updated to time first clinical information received.
in Loop 2, if the criteria question requires chart notes and the MDO did not attach what close option can we select?
RFI w/ Clinicals
If the client is standard, and you cannot answer the criteria questions via OBC and the request has no clinical information, what is the best close option?
RFI without clinical.
It is best practice to use the Auto Note tool to utilize the RFI templates.