Access & Verify
What 3 pieces of information about the caller do we need to verify? (this is caller info, not about the patient)
First name, first initial of last name, and title
What is the difference between paid and rejected claims?
Paid claims were processed successfully at the pharmacy, rejected claims did not go through.
What is the smart key HICL?
5 digit code that is only used for PLAs
What are the 2 types of authorizations?
PA and PLA
Who in class said they have not combed their hair since 2014?
Vicky
When your caller only wants the fax number for Express Scripts, where do we document?
If an account did not load, we do not document.
If there is no recent claim on file, where do we go to to look up a medication?
6 digit code that groups the Brand and Generic medication of the same strength together
Who are the only people who we can build a CUPS case with?
Someone from the pharmacy
What is the button in Drug Coverage Details that we never touch?
Add Patient Level Prior Auth
What are the 3 pieces of the eligibility triangle?
Member info, Group info, Family coverage
What is the difference between original quantity and dispensed quantity?
Original is what the Doctor prescribed, dispensed is what the pharmacy is running
What are we looking for to tell us that a PA is availabled?
A phone number in drug notes
What are the 2 types of Prior Auths that are interchangable?
TPA and ST
What is Kim's favorite food?
Chicken Wings
What is you standard introduction as a PAR?
Thank you for calling. My name is __________, a Prior Authorization Representative. May I please have the patient's member ID?
What is the minimum number of letters we need to look up a medication?
3
What is the difference between covered and not covered?
Covered is on the formulary, not covered is not on the formulary.
Before you build an FCR case, what button are you going to click on to show which medications the plan favors?
Preferred Products
If I need to transfer a call to member services, what am I going to say in my mind?
BYE FELICIA!!!
Member ID, Name, DOB, Address, Zip Code, Phone Number, Case ID, Rx Number
If the doctor office is calling about the Botox 100 and you see a rejected claim for Botox 200, what should you do?
Go to Benefits, and then Drug Coverage, and look up up the drug notes for the 100
What is an NDC number?
This is the manufacture of the medication
What is a multiple edit?
Medication that requires more than 1 authorization
What is a Prior Authorization Rep's worst enemy?
Speed