QA
True/False?
When calling PBM, your introduction should include full drug name ex. "Aimovig erenumab-aooe" with every new agent you speak to.
True.
Can you use your payor intelligence tool to find a PBM if none is listed?
Yes, you are encouraged to use your Payor Intelligence tool however this should not be your only option. You are expected to exhaust all other resources. Examples: Reading your case notes, reviewing the SRF information to ensure info was keyed in correctly, Google PBM info/phone numbers etc.
What do you do when a representative tells you there is a PA on file and it was denied?
Gather denial information (reference number if possible and denial date) then ask if and HOW we are able to appeal their decision.
What do you do when a representative tells you they received an appeal and it was denied?
TRUE/FALSE
You can work BI with intake incomplete.
False.
What's considered and "excessive hold time"?
Being on hold after 45 minutes.
What do you do when the PBM listed in salesforce is different than the information provided to you?
You update the information in salesoforce and notate your changes in case notes.
TRUE/FALSE
If rep tells you PA was approved, is your next step to change the outcome to "Coverage Identified" on case?
FALSE, after a rep tells you the PA was approved you have to first check what status the case is currently in, then review the case notes, then next step to PA if needed, then add all PA doc info, then have someone review your work, then change outcome if granted approval.
TRUE/FALSE
Can you change case outcome to "Coverage Not Identified" in scenario where rep tells you the appeal was denied with no option to appeal again?
True, upon reviewed case work you can change outcome to coverage not identified.
Who's your favorite UC?
Serena Swanson
TRUE/FALSE?
The proper greeting when speaking to an insurance representative is as follows:
"Hello, my name is [Name], I'm calling on a recorded line to obtain benefits on behalf of the provider for Aimovig Erenumab-aooe."
FALSE
You should never say you're calling on behalf of the provider. You will get dinged points.
What do you do if no coverage is found with 3+ insurance plans?
Task CM so they can follow up with patient and obtain needed insurance info.
TRUE/FALSE
You can next step a case that's currently in BI to PA then to Appeals.
True,
If a case is under investigation, and you find out there was previously already a PA submitted but the rep tells you it was denied then says you can appeal this decision, it is possible. Lots of "next step" windows but not a rare scenario.
What do you do if rep says appeals are handled by another company and you call and they are closed?
Notate a well detailed summary of your interaction with that agent and include business hours of appeals department that is closed.
If this trend occurs repetitively, contact a Sup/UC via skype or by raising you hand. In this case, you may receive a new list with different payors.
"Thank you [Rep Name], for your assistance in determining coverage for my patient. Just to confirm, the patient has no coverage through United Health Care with the information provided and has been terminated since 01/01/2018."
Yes, the statement is: Appropriate, Polite and Accurate.
What is a commercial plan?
AKA Private insurance plans, they are any kind of insurance that is not paid for by the government.
What do you do if the prior authorization is approved but the "current step" in salesforce is to conduct BI #1?
You will next step until case is "caught up" real time and ensure you gather all necessary information from rep.
You will still conduct BI
You will still select "PA Assistance Required"
You will enter PA Approval number, Effective/Term date for Auth, any additional restrictions/information provided by rep
You will call Sup/UC/Floor Support to verify all info is entered correctly to change outcome to "Coverage Identified"
What do you do when a rep tells you they can't provide appeal status due to 3rd Party Restrictions?
Try calling again to find the "weak link". If all else fails, last option is to task CM.
What should you do if a payor is 3rd Partying you and is saying we are not complying with HIPAA?
You request to speak to one of their supervisors after explaining that we have written consent from the patient to obtain information on their behalf, we are in compliance with HIPAA.
Should you repeat your intro to every different agent you speak to? Even if you're transferred to a different department on the same call?
Yes and yes. Every new agent you speak to you are required to tell them this call is recorded for quality and training purposes and include the drug name.
What is Medicare Part D and how do you qualify?
Covers prescription drugs. To participate in a Part D program, you must qualify for Parts A or B.
1 rep says the PA was approved. They cannot provide you with any approval number nor reference number due to 3rd party restrictions. What's your next step?
It is recommended you call back 1 or 2 more times just to see if another agent can confirm that approval and possibly provide you with the information you need. You cannot "next step" a PA approval without an approval number.
Yes. Some insurances will not have medication on formulary, they will request you submit an NFE (aka Non-Formulary Exception) which is requesting insurance to consider medication.
What do you do if rep doesn't provide Group, BIN & PCN?
Add to Additional Instructions that info was not provided.