Authorizations/Prior Authorizations
What is the system called for processing Prior Authorizations (PA)?
Prompt PA
Green Dollar Sign
Under the deductible message what are the 3 benefit stages that can show?
Deductible, Initial and Catastrophic
What 3 prescription drug plans are Stand Alone?
Value, Basic or Premier
Where can you find a member's copay information?
DEBUT
What is the code for pharmacy override?
03
How can you tell if a medication is not covered?
It will say "Not covered" in the coverage column.
When researching claims where would you confirm amounts applied to the deductible?
Call Connect detail benefits panel.
What is the product code for a Group Plan?
MG, MGP, MGR, MGO, MGF
Note: We do NOT handle these plan types.
When replacing an ID card, what information should be verified?
PCP, address, verify another card has not already been requested.
It will say Prior Authorization, B vs D or Step Therapy.
What section in RxConnect Pro would you find the deductible?
Under benefit stages
When researching denied claim, what does 082 error code mean?
Prior Authorization is required.
What is the product code for Medicaid?
MCD
Where in CRM can you see if the member met their deductible?
Accumulators/Accums
Which document do you use to verify if a member needs a referral?
PAL List
What is the code for Coordination of Benefits (COB) override?
090
What coverage does Hepatitis B fall under?
Part B vs. Part D
Which plan types do you handle?
Where do you do a PCP change if the member already has a provider in mind?
CRM PCP Change Template
Who can submit an authorization?
Member, Provider, Member Representative/POA, Caller with Verbal Consent.
Where do you locate member's pharmacy benefit grid?
RxConnect Pro
Name 2 of the most common immunizations members may call about.
Do we handle Integrated Plans?
No
Where do you submit your PTO hours?
Workday - Manage Absence