Eligibility
This information needs to be provided when member is active.
What is the type of plan, dates of coverage and the assigned pcp
For vision service, the member can contact them.
Who is VSP?
If the provider has questions about the medication denial, they can speak to this department.
What is the pharmacy department?
When services require approval by the insurance company.
What is a Prior Authorization?
If the member enrollment does not match the state enrollment.
What is an eligibility discrepancy?
They will coordinate Transportation for a member.
Who are the 9 transportation brokers?
Covered medications will be located here.
What is the formulary?
Prior authorizations are based on this.
What is medical necessity?
Enrollment updates are forwarded here.
What is the enrollment tier 1 call tracking box
The member wants an email of available dental providers. (call coding)
What is Material Req, Activity Code-Provider Directory ?
This is the system where medication will be processed.
What is CVS Caremark? or Client Online Services?
A reconsideration of a denied service.
What is an appeal?
A term used when the member can't receive services when needed.
What is Access to Care issues ?
Some examples are:
• Attempted suicide • Danger to self or others
• So much functional harm that will likely cause death or serious harm to the body
What are Crisis calls?
How the MP formulary indicates cost amount of medication.
What is the Tier pricing?
This department will handle the review of an authorization request.
What is the Utilization Management Department?
This is the email to have Medicare enrollment updated.
• Education and counseling about birth control provided during the physical exam
• Contraceptive supplies
• Pregnancy testing
What is family planning?
When one medication requires the trial of another medication.
What is Step Therapy?
An expedited request must show proof of this.
What is to prevent serious deterioration of member’s health or jeopardize their ability to regain maximum function