Verification
What is the Intro to the caller?
Hello my name is …. a Prior Authorization Representative. May I please have the patient's member ID?
What information you use to find a patient's account, mention 3?
Member ID
first and last name
DOB
zip code
What is the first thing you need to do in One PA and why?
search a case to avoid create a second one
How many letters we have to enter to find the prescription?
at least 3 letters
What does FCR stands for?
What does FCR stands for?
Name 4 pieces of information that we can verify?
Member id
complete mailing address
Date of Birth
Phone number
Customer's full name
When we warm transfer do we have to select the drop-down arrow on the icon?
No
If someone is already working on a case what are the steps you need to do to release the case?
Send a message to the person through Webex if they already finish the case
Where can we see the dispensing size and form of the drug?
manufacturer pricing
If a patient/member is calling what should we do?
inform the status of the PA and tell them their doctor needs to call us
What does HIPAA means?
Health Insurance Portability and Accountability Act
What can be found in the PIP section mention 4?
member name
preferred name
date of birth and age
gender
address
status
member ID
email address
dedicated customer service number
group number & name
How do you recognize if a case is still pending?
There is a lock next to the case number
Do we mention alternative options to a caller and where we can do that?
depends on the case and it's on preferred products
What do we do when we see a rejection code 79?
We need to check the date when the patient can refill and run a coverage check using that date
Mention 2 examples of Protected Health Information
Patient name + medication name, SSN+RX number, Patient name + diagnosis
In what section of CSP we can find the previous communication?
Services > Communication
What information do you need to confirm to start a PA, mention 4?
Prescriber information
NPI
medication details
patient's phone number
If a prior authorization is needed and the there is a bullet point highlighted in blue light do we have to create a case?
YES
How do we calculate the Net Rx cap?
AWP x Qty
AWP=Average Wholesale Price
Qty=Quantity
Caller is telling you this is an emergency involving the health of the patient what do you need to do?
transfer to a Patient Consult Pharmacist
What do you need to do to find out a second account?
Go to Search > select alternate eligibility search.
When you finalize a case you have to select add log what information you have to input here?
Select the verbal decision, input information of the caller, direction code, change disposition to Live answer, add a comment of the result.
If we run a coverage check after a case was completed in One PA and we see a rejection code 88 what do we do?
inform the caller the retail pharmacy needs to contact PHD for assistance
If the medicine is not covered under the plan to whom could we transfer it?
If ESI handles the admin appeals we transfer to the appeal coverage.