CALL FLOW
This must always be given before asking benefit questions.
What are codes and disclaimer?
This is never a legitimate way to buy and bill a drug
What is through a pharmacy?
The state that regulates a plan, which may differ from where the patient lives.
What is the policy state?
This POS is used when infusion therapy takes place in the specialist office.
What is POS 11
A generic reference number always starts with these two digits.
What is 00
You must disclose this before sharing PHI.
What is being on a recorded line?
If a rep confirms buy-and-bill but ignores the frequency question, you should ask this.
What is “Can we buy and bill the drug every time the patient is infused?”
A rare but important identifier for a plan, also called Group ID.
What is account number or group number?
This POS is used when treatment takes place in the patient’s home.
What is POS 12- Patient Home
You should NOT use this as the official reference number if the rep suggests it.
What is the authorization number
This IVR option is selected first.
What is Provider?
Drugs under the medical benefit may be restricted by this type of list.
What is a carve out list / drug exclusion list?
This may also be asked if the group name is not available.
What is employer name or plan name?
This POS refers to an off-campus outpatient hospital.
What is POS 19
If B&B is only available after authorization approval, document this.
What is “B&B is based on PA approval”
Name all standard IVR prompts in order.
What are Provider, Eligibility, Benefits, and Coverage?
If a rep says “The pharmacy is carved out to ___,” you should ask this to clarify buy-and-bill.
The Provider has this in office and wants to administer to patient and bill the medical plan is this allowed?
Asking for this helps confirm the exact plan to avoid confusion.
What is the plan number or plan description?
In POS 12, the patient typically does this with the medication.
What is self-administer the medication?
If a rep directs you elsewhere for carve out information, they may tell you to contact this.
What is Specialty Pharmacy (SP)
Reps need this first before providing benefits
What are Jcode, admin codes, dx code and disclaimer.
If no Buy and bill what goes into PA section of Callsheet?
No BB and Specialty Pharmacy phone number we use.
The key resource for how to rephrase tricky questions with reps.
What are Rephrasing Tips?
Differences between POS benefits should be documented in this section.
What are the Call Notes?
This phrase documents that only in-network providers may Buy & Bill.
What is “Only INN providers can BB”