RPh Completion
When completing RPh‑approved PAs, this part of the notes must be added at the end of the PA note, regardless of whether the Q‑set required editing.
What are the RPH NOTES?
If the request is urgent, both the denial and approval databases must have this status marked.
What is “Urgent”?
You must check the cover sheet, PA form pages, and first page of medical records to determine if the fax has this designation.
What is an urgent request?
This term is intentionally excluded from urgent qualifiers because all PAs are processed as quickly as possible.
What is ASAP?
When the protocol shows Ambien 5mg but the drug dropdown shows Ambien 10mg, this must be checked to find the accurate strength.
What is the claims history or RxClaim Rej?
This RPh outcome occurs when a drug was not in CAS Drug Dropdown or on the long list of known NIC Meds and the RPh confirms it requires no authorization.
What is NIC Med?
Every Max Quantity case is processed as this number of separate PA databases.
What are two databases? (One denial and one approval)
You must never attach a document to a PA database that has this status. (4 answers)
What is closed, Pending QC, ePA, Doom PENDING?
If no fax number exists on both the PA form and CAS MDO record, this placeholder number must be entered.
What is 9999999999?
After correcting a strength conflict, your note should look something like this: “PER CLAIMS REJECT FOR AMBIEN 10MG…” followed by this statement.
What is “CHANGED PROTOCOLS” or "CHANGED Q#?
If an RPh indicates this two‑letter phrase, the PA needs approval with quantity restrictions removed.
What is “NO QVT” or "NO QUANTITY"?
When the RPh provides a corrected or clarified requested quantity, this must be changed to match it before selecting RPh Deny (Max Quantity).
What is the requested quantity in protocols/criteria and PA Info?
If no eligibility is found for a member, the document should be reassigned to this queue.
What is the Follow Up Queue?
This field must always be watched carefully because a father/son pair with identical names can lead to catastrophic mis‑assignment.
What is the Date of Birth field?
For ePAs, this special display shows the MDO’s original submitted answers and is used to identify conflicting information.
What is the ePA Criteria tab?
This Close Option is selected when the CSR cannot complete the PA due to missing criteria or unclear RPh documentation.
What is RPh Action Needed?
For the second database, quantity in the Q-set must be adjusted to match this exactly.
What are the RPh notes (approved quantity)?
When creating a new PA, this classification must be selected based on the form type—not the drug requested.
What is choosing Clinical vs. Benefit Reconsideration?
This identifier may appear due to other departments sending faxes, but CSR1s replace it with the NPI if the NPI is present on the form.
What is a DEA number?
This option must be chosen when research fails to uncover any approvable criteria, leaving the clinical decision to pharmacists.
What is Send to RPh Queue?
To remove quantity under NO QVT instructions when fixing a record per RPh notes, the CSR must use these keyboard commands to access the quantity fields in RxClaim.
2, ENTER, then F7
These two fields are always mandatory when the Close Option selected is RPh Deny (Max Quantity).
What are Requested Qty and Days Supply?
These two appeal‑related destinations hinge on whether a patient signature exists; one is appropriate for signed appeals, while the other is used when the signature is absent.
What are the Recon/Appeal Letter queue and the Medical Records Rec. queue?
These two areas must ALWAYS be reviewed before proceeding because they may change the entire outcome of the PA.
What are PA History and Member Notes?
When an ePA that was initially approvable is changed to denied, through re‑answering, this system-generated record may appear in RxClaim and must be canceled.
What is a System Services (SS) PA record?