Tools
CVS Caremark Prior Authorization system used to submit and check SGM PA status.
What is CAS?
SGM (CAS) PA Help Line
What is 1-866-814-5506?
We are filling a quantity and/or day supply over the plan's set limits for product dispensing.
What is M/I Day Supply?
The source document TSRC-PROD-014697.
What is Specialty Benefits Verification Talk Track Scenarios?
This edit failure appears when…there is a Manufacturer PAP Card MAJ bill code loaded on to the patient’s insurance profile but no valid MOP linked to the bill group.
What is PAP card found?
Centralized CVS Specialty Pharmacy Information Reference tool.
What is Pharmacy Reference?
Where I can find copies of previous approved PA's.
What is images?
Anything under or over the plan limits will create this rejection including excess quantity, day supply, drug cost submitted, and refill interval or utilization requirements.
What is Plan Limitation Exceeded?
Source Document TSRC-PROD-028522.
What is SPRx Task Contact Frequency and Max Attempts for CORE Therapies?
This edit failure appears when…there is a potential error with the prescription entered or when a Medicare plan has limited the amount of refills per prescription and a new prescription is needed.
What is Refills Exceeded?
Locate patients that have CVS Health as their Pharmacy Benefit Manager. Provides eligibility, prescription plan design and processing information, override and PA details, demographics, prescription history, as well as other client related details.
What is Peoplesafe?
Action taken on day 4 in the Epic Prior Authorization follow up protocol.
What is 3rd follow up/final attempt?
DAW Code on prescription is not allowed by the plan. New Rx may be needed from the prescriber.
What is M/I DAW Code?
Document number for SPRx Benefits Verification Process.
What is Source Document TSRC-PROD-013375?
This edit failure appears when…the business unit being processed is most likely not contracted with the insurance.
What is restricted payer?
Tool for verifying Medicare eligibility details and coverage.
What is Connex?
Step one of a SGM (CAS) & Epic (EPC/EPT) PA initiation.
What is utilize data viewer to obtain clinical documents needed for prior authorization?
The prescription serial number is invalid or missing.
What is M/I Scheduled Prescription ID Num?
Document number for SPRx Benefits Verification PrudentRx Copay Optimization Program.
What is Source Document TSRC-PROD-031083?
This edit failure appears when… no ICD code or an invalid ICD code is present on the patient profile that is not covered by the Major Medical Payor.
What is ICD PAT check?
BCBS Prefix finder for identifying the patient's home plan.
What is BCVS Alpha Prefix List?
Access to electronic health records for enrolled providers that can be utilized to request PA's on their behalf.
What is Data Viewer (EHR)?
Indicates the claim was sent to the PBM, but no response was received from the plan on the claim status.
What is Host Not Responding?
Document number for Specialty Benefits Verification Common Rejections and Solutions.
What is Source Document TSRC-PROD-016073?
This edit failure appears when… NDC Change is needed for a Biosimilar.
What is DNF Non-Preferred?