Override Guide
If you are working a request for GA Medicaid-Peach State and the medication is listed in ESI as "Brand Multi-Source" & the Generic is Non-Preferred/Non-Formulary (meaning Brand is Plan Preferred) & the medication is classified as a Maintenance Product; what Compass GCN Expansion Selection would you use & what would your Brand/Generic Indicator be set to?
Auth Placement: GCN, EXPAND_ACROSS_THOSE_MATCHES_SAME_DOSAGE; Brand/Generic Indicator: Brand (SS & MS)
1. You are working a member-initiated request - when is PSS required vs when is it not?
Not required Answer:
• Excluded Medications
• Tier requests (when medication is on an ineligible tier)
• Benefit Denials (Member was not eligible on the requested dates of service, PAP denials, etc.)
• Member/member representative (AOR/ POA) submitted request with enough information to approve without needing PSS
• Request Reason is Safety Edit 925 Only
• Case is being denied for “Non-Medically accepted indication” and is submitted by the provider
Required:
•Medically accepted diagnosis provided (unless the case would be a denial regardless of presence of PSS.)
• The member provided a non-medically accepted diagnosis
• The member did not provide a diagnosis
• The member provided only 1 tried and failed medication, when 2 are required and unable to verify additional tried and failed medications within the claims.
If you have a request that has a J-Code, Buy and Bill is Indicated, and there are Rx claims & you are unable to obtain clarification after outreach, would this be considered a Part B or Part D request?
If no answer was received: Since claims are being run at the pharmacy the medication should be worked under the pharmacy benefit as a Part D medication.
Which LOB’s can we send to the RFI queue?
NY HIM, CCHP-WA HIM
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If you are working an Organization Determination case and the medication rejected for PA required and you need to place an override to allow the medication to pay under Part B, what Compass Override Selections would you use? (Hint-Use Tab 4. Medicare)
Auth Type: A: Prior_Authorization; Clinical: Yes; MED D: No
You are working a member-initiated request, you have determined that PSS was NOT provided with the original request and it is needed to work the case, how would we proceed?
1. Complete the questionnaire (If applicable).
2. Select “No” for the Supporting Stmt Received w/Original Request radio button.
3. Make outreach for the Supporting Statement and any additional information that is required to decision the case.
4. Document the call in the Contacts tab following procedures in Step 40.
5. Select “Yes” for the Supporting Info Requested radio button.
6. Refer to Step Action CD and OD RFI Outreach Process for additional steps.
If you are working a compound that contains a medication listed in the Formulary Search Tool as an "Immunosuppressant" the patient's diagnosis is related to a kidney transplant, ESRD Indicator is present in ESI and the Qualified Flag is "Not Present" would this be considered a Part B or Part D request?
Member HAS an ESRD indicator in ESI and the Qualified Flag is Not Present -then this would be a Part B medication.
What is the new process for TX HIM Pre denial?
Select PRE-DENIAL NOTIFICATION from the dropdown.
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If you are working a case for an Exchange LOB, COB of 3 is being ran in claims and the Cost Exceeds Max, what field do you need to update to "NO"?
Per Claim Ingredient Max Override
When it comes to choosing a request reason, in what instance would we use the request reason of QL vs PS/ST+QL?
QL:
(1) When approving over the plan quantity limits (QL) as Part D. This requires a Patient Level Authorization (PLA). A PLA cannot be placed if the drug/product is not coded on the formulary with QL.
(2) Drug is on the formulary as BvsD and QL, and is determined to be Part D
(3) PA auth already approved and on file, and drug is only rejecting for over the quantity limit
(4) PA auth required by FST, test claim only showing rejection for QL
PA/ST+QL (Prior Authorization/ Step Therapy+Quantity Limit): PA/ST drug with QL, and request is over the QL
If you are working an IVIG medication for a Centene Medicare LOB; the patient has a diagnosis of D80.6, the medication is being administered in the home and the provider is asking specifically for the drug to be covered under Part D, would step would you take?
You would Deny the CD case and create a new OD case.
What LOB requires the provider to use a special form for it to be a valid case? And what do we do if it is NOT sent on the correct form?
AZ HIM
Send the case to Secondary Review to be reviewed (please note this is not applicable for ePA its for facsimile cases only)
1. Status: In Progress
2. Status Reason: Under Secondary Review.
3. Internal Note: REQUEST WAS NOT SUBMITTED WITH CORRECT FORM
4. Submit case.
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If you are working a Tier Request for a Brand Single Source Product and the case leads to an approval, what does your Brand/Generic Indicator need to be set to?
Brand (SS & MS)
When a case is missing basic information what steps would you take and what template would you use before sending to s/r?
Step: Call the provider to obtain the missing basic information and document the call following Step 40
If unsuccessful: Send the case to Secondary Review.
1. Status: In Progress
2. Status Reason: Under Secondary Review.
3. Internal Note: Unable to locate Missing Basic Information <<INCLUDE WHAT IS MISSING>>. Please see outreach attempt within the Contacts tab.
4. Submit case
If you have determined your case to be a buy and bill (the request is for a J-code and the provider will be providing & administering the medication) and you are working a Medicare Duals LOB what step should you take?
Send the case to Secondary Review; using internal note: REQUEST IS FOR A BUY/BILL DRUG CODE
. Please list all examples for medical billing and the proper process if it IS determined to be a medical request?
Drug listed as a J-code with no pharmacy claims
• Procedure codes with no indication a medication (A-codes, S-codes, Bcodes, E-codes)
• Drug is being supplied by the provider (“Buy and Bill” or “provider to supply” listed on the request)
• MS Exchange – HIM Medical Requests
• SC Exchange-HIM requests for: Yescarta, Kymriah, Tecartus, Breyanzi, Abcema, Luxturna, Amondys-45, Zolgensma, Spinraza, Zynteglo, Carvykti, Skysona (Exondys-51, Vyondys-53 and Viltepso Pharmacy is allowed but Medical is preferred)
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If you are approving a medication that costs $110,575 what does your Compass Override Selections need to be and what would your Next Rx Cap Amount need to be set to?
Auth Type: A: Prior_Authorization; Per Claim Ingredient Max Override: Yes; Net Rx Cap Amount: 111,000
Name some instances in the step action that would prompt us to send a case to s/r if the request does not indicate intent for coverage & what internal note template would we use before submitting?
• Police Report
• Vacation requests
• AOR forms
• Additional info to an open case
• A Prescription with no indication of a coverage request AND the medication listed on the prescription does not require an authorization to pay at the pharmacy
• Misdirected transition fill letter with no indication of a coverage request
• Request stating the member/provider is no longer in office
• Patient Assistance Program (PAP) enrollment letter
• Lost, stolen, or damaged medication
If you are working an IVIG medication with a Part B diagnosis code but are unable to verify where the medication is being administered after making an outbound call to the provider; how should you deny the case & what letter templates should be used?
Deny the case for Medical Necessity Not Met using Letter Template: No Med Doc; STND & External Template: BvsD: CMS Chapter 6
How can we determine if the case is a valid appeal?
Same drug name (brand versus generic or ER versus IR are DIFFERENT)
• Same strength
• Same Quantity
• Same dosage form (i.e., tablets, capsules)
• AND be within the correct duplicate or appeal timeframe (varies per LOB and case type, i.e., Medicare v. Medicaid)
o Refer to the Quick Reference Guide Exchange-HIM document for timeframe requirements.
o Possible Appeals cases: these must also ask for an appeal somewhere on the request (Appeal of decision, request is addressed to appeals dept, etc.)
NOTE: if you have a case where the requestor does one of the following, this is NOT considered a valid appeal case and should not be sent to the Duplicate or Secondary Review Queue:
▪ Faxing back a denial letter with missing/requested additional information
▪ Faxing back a denial/RFI letter agreeing to change to a formulary/PDL medication.
▪ A request indicating “reconsideration”
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