PA History
You have a request for Wegovy, but you see two denials on file. What is your next step?
Check if its the same provider
I just ran my test claim and got a paid claim, I can just abort the case, no pa required.
False, run it out to make sure it pays 90 days out.
After we open our case in Assigned what is the first step?
Open fax attachments, verify member info and urgent flags
If Im missing information I can make an obc to see of I can complete my request?
False, in Loop 2 we do not make obc's
When making an obc I can hold 2 minutes?
False, 1 minute
What tab can you find the PAG?
PA details
I have a request for an opioid, it rejects 70 days out does it need a new pa?
No, we only run opioids for 60 days
You make an OBC to MDO for additional information and its unsuccessful, the request has already been faxed with clinical, what is my next step?
Forward to RPH
Per WI of I'm missing the MDO fax number what default can I use in case of missing MDO fax?
999-999-9999
If your able to approve a case on a call which time stamps would you use?
You would set to now for completed date and verbal notification date
If I need help with an override where would I look to find override instructions.
Guidelines/Specific
When running a test claim for Dupixent you get the rejection number 866-814-5506, who handles this rejection?
Specialty
Its not necessary to change the drug in the drug drop down if its already populated?
False, always update the drug dropdown box
In duplicate denial, I have a case that needs to go to appeals handled by CVS, what are my next steps?
Download criteria, pa details, any attachments and RightFax to appeals using transfer to appeals coversheet
We always need to make a note of who we spoke to, first name, last initial and title?
True always notate who you spoke with
Where can I find the denial letters?
Communications Tab
When running a test claim the rejection is a 70 without a phone number, what would be my next step?
Check RMT to see who handles the request
Opened request and the new fax attachment is now marked urgent, what do I need to update now thats its urgent.
Update urgent flag in CAS and update my request received date to reflect the new urgent timestamp
Per smart routing I need to verify my criteria, if the criteria is wrong I need to abort the case?
False, update to correct criteria and fax out with clinical using the RFI incorrect criteria option
If the MDO requests the criteria to be faxed, do I need to put my completed received date when faxing out?
No, only when forwarding to the RPH
Where can I find the outcome of the request?
In PA HX under resolution
After running my test claim and inputting my rejection number and phone number, no criteria is available what should I do?
Send to Sr box (email template) for missing criteria
Received a request without any clinical and ran my test claim, picked my criteria and updated mdo info, what are my next steps?
Simply fax out without clinical, no obc required
If the request asks for documention do I need physical chart notes?
No, documentation can be given in the answer box or verbally.
What is our most common pa phone number to give to the mdo if asked for a callback number?
800-294-5979