PHONE A FRIEND
IF THE CALLER HAS QUESTIONS ABOUT COPAY WHO DO YOU TRANSFER THE CALLER TO?
MEMBER SERVICES/CUSTOMER SERVICE
HOW MANY PIECES OF INFORMATION DO YOU NEED TO VERIFY A PATIENT?
4
IF YOU ARE UNABLE TO ACCESS THE ACCOUNT OR CASE, WHERE DO YOU DOCUMENT?
NO WHERE
WHAT REJECTION CODE WOULD YOU SEE IF THE MEDICATION REJECTED FOR QUANTITY LIMITS?
76 PLAN LIMITATIONS EXCEEDED
WHAT IS A PAR?
PRIOR AUTHORIZATION REPRESENTATIVE
IF YOU NEED ASSISTANCE WITH THE ACCOUNT OR CREATING THE CASE, WHO DO YOU CALL?
HOW MANY PIECES OF INFORMATION DO YOU NEED TO VERIFY A NON-PATIENT LEVEL CALLER?
7
IF THERE IS AN EXPIRED CASE ON FILE THAT MATCHES THE PATIENT AND MEDICATION THAT BEING CALLED ABOUT BUT THE CALLER DOES NOT WANT TO CREATE A NEW CASE, WHERE DO YOU DOCUMENT?
EXPIRED CASE C360/ONEPA
WHAT IS A 78 REJECTION?
COST EXCEEDS MAXIMUM/ CUPS
THE CALLER WANTS TO KNOW THE PREFERRED ALTERNATIVES BUT NONE ARE LISTED. WHO DO YOU CALL?
PC RPH
YOU HAVE CREATED THE CASE AND IT IS LEADING TO DENIAL, WHAT DO YOU DO?
CALL UMP
WHAT IS THE REQUIRED INFORMATION TO AUTHENTICATE A PATIENT LEVEL CALLER?
PATIENT FIRST NAME AND PATIENT LAST NAME
IF THE MEDICATION IS COVERED AND NO PA IS NEEDED, WHERE DO YOU DOCUMENT?
ESD
WHAT IS A REJECTION 66 AND WHAT ARE THE NEXT STEPS?
PATIENT AGE EXCEEDS MAXIMUM AGE
CHECK DRUG COVERAGE, IF MEDICATION IS COVERED, ADVISE CALLER TO HAVE RETAIL PHARMACY CONTACT PHARMACY HELP DESK
WHAT IS PHD?
PHARMACY HELP DESK
WHEN LOOKING AT THE DRUG NOTES, YOU SEE A QD CASE BUT IT DOESNT HAVE A NUMBER BESIDE IT, WHAT DO YOU DO?
CHECK BENEFITS FOR BCR, IF BCR IS LISTED- CALL BCR, IF CLIENT IS LISTED REFER TO CLIENT
NAME ALL PIECES OF INFORMATION NEEDED TO PROPERLY AUTHENTICATE A NON-PATIENT LEVEL CALLER
REQUIRED INFO: PATIENT FIRST NAME, PATIENT LAST NAME, NAME OF THE REQUESTOR, REQUESTER'S RELATIONSHIP TO PATIENT/TITLE, DRUG NAME
ADDITIONAL INFO: MEMBER ID, DOB, ZIP, PATIENTS FULL ADDRESS, PATIENTS PHONE # WITH AREA CODE, CASE ID #, BENEFICIARY ID #, HICN, SSN, PRESCRIPTION #
IF YOU ARE NOT TRAINDED TO HANDLE CLIENT/MED D ACCOUNT, WHERE DO YOU DOCUMENT?
ESD
WHAT SHOULD YOU OFFER FOR A REJECTION 70?
PREFERRED ALTERNATIVES
WHEN ACCESSING DRUG COVERAGE DETAILS, WHAT MUST WE CLICK TO VIEW ALL PA/PLAS ENTERED BY ESI/CLIENT PRIOR TO GOING TO ONEPA/C360?
AUTHORIZATION SUMMARY
IF THE CALLER REQUESTS A SUPERVISOR BUT THE CASE THEY ARE CALLING ABOUT IS IN APPEALS, WHO DO YOU REACH OUT TO?
APPEALS
WHEN YOU RECEIVE AN INTERNAL TRANSFER, WHAT MUST YOU ASK THE REPRESENTATIVE BEFORE ACCEPTING THE TRANSFER?
HAS THE CALLER BEEN HIPAA VERIFIED/AUTHENTICATED????
WHEN THE CALL IS REGARDING AN APPEAL REQUEST, WHERE DO YOU DOCUMENT?
BOTH C360/ONEPA AND ESD
THE PATIENT NEEDS 4 PENS FOR 28 DAYS (4/28). WHEN YOU RUN YOUR COVERAGE CHECK IT REJECTS FOR 9E:INVALID QTY, SUBMIT IN 0.75ML. WHAT IS THE QTY THAT YOU WOULD SUBMIT FOR COVERAGE CHECK?
4 X 0.75= 3
HOW DO YOU ADD DOCUMENTATION TO A CASE IN ONEPA?
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