ADT/CALLER CODE
THE MEDICARE AUTHORIZED INITIATION DATE AND TIME (ADT) STARTS WHAT?
WHAT IS THE TURNAROUND TIMECLOCK FOR PRIOR AUTHORIZATION CASES
THESE CASES ALLOW BACKDATING
WHAT IS NONE OF THEM!
L58A NON URGENT DENIALS-DOES IT REQUIRE A CALL OUT OR NOT? AND WHO?
THE PARTIAL INFORMAITON INDICATOR STARTS WHAT?
WHAT IS THE TURNAROUND TIMECLOCK FOR EXCEPTION CASES
AN APPEAL MUST BE FILED WITHIN HOW MANY DAYS OF A DENIAL?
WHAT IS 90 DAYS
the patient is transferred to CRD from UCARE ABOUT A MEDICATION
do NOT educate the caller. ALWAYS build the case. The case is initiated and TAT Timers should start
WHO CAN INITIATE A CASE
prescriber or Pharmacy.
PATIENT- APPROVALS
PRESCRIBER- ALL CASES
Patient/AOR calls in for STATUS of the case (TELL ME THE CALER CODE AND ANY ADT ACTIONS)
PAR uses the Patient Caller Code and Selects the Action Taken of "STATUS". Contact RS to remove ADT if ADT was automatically set due to the incoming call for STATUS.
ON THESE CASES MUST YOU ASK THE POST SERVICE QUESTION
NONE OF THEM!
the patient calls CRD directly questioning why they cannot get a medication at the pharmacy due to prior authorization
Always educate the patient/AOR and offer choices regarding case initiation and TAT Timers. ALWAYS offer to build a case or not build a case and allow caller to decide
If there is a denial on file, an appeal must be filed or wait the respective amount of days ? before a new review can be started
L4NA = 180 days or they can file an appeal
PRESCRIBER-ALL CASES
PATIENT- ALL CASES
TURN AROUND TIMES FOR URGENT AND NON URGENT CASES
24 HOURS FOR URGENT AND NON URGENT
EDUCATE PATIENT AND START A NEW CASE -If the case was withdrawn by prescriber or patient, then a new case can be created.
PRESCRIBER CALLS IN FOR A MEDICATION THAT REQUIRES A ST CASE AND FCR WHICH CASE DO YOU COMPLETE FIRST?
MNUA NON URGENT
PRESCRIBER- NO PATIENT- ALL CASES IF 6 HOURS OR LESS FROM TAT
you have an EXCEPTION case AND SOME criteria questions are answered BUT caller is unable to complete the criteria (WHAT DO YOU DO WITH THE ADT)
call an UMP to see if the PII needs re-set.* ONLY AN UMP can determine this.
WHERE DO WE SEND VACATION 76 OVERRIDE REQUESTS TO?
WHAT IS SEND AN EMAIL TO CRD UCARE Support <CRDUCARE_Support@express-scripts.com>
A MDO calles in for an FCR case , there are no preferred alternatives listed in eSD
move on UNLESS the caller asks what is covered or what the preferred alternatives are. ALWAYS reach out to the centralized counseling line to get the preferred alternatives.
• MUST VERIFY HIPAA WITH THE CLIENT
• Ask the UCARErep if they will be staying on the line for the review or if they will be directly transferring the caller.
• At this time you are REQUIRED to bring the member on the line with you and the client.
• You MUST give the disclaimer once the member is on the line.
• ((( REMINDER THAT ANYTIME A NEW PERSON COMES ON LINE MUST RESTATE DISCLAIMER)))
• Do not continue until the member is on the line
• Once the member is on the line then you proceed to ask med name , strength,QTY and day supply and build the case if necessary. If the case is already created and the client calls for a status update or to request you to call the MDO to try to complete the case you must complete their request once HIPAA is verified
UCARE has specific documentation requirements for notification and status calls. You must include
Name of person you spoke to
Title of person you spoke to
Medication Name and strength
If approved – the dates you advised them of for approval
If approved – if you gave them the case number or not.
If denied – document if you provided denial reason or not.
If denied – if appeals information was provided.