Authentication
When authenticating accounts what article do you use?
Article: How do I authenticate an account?
If case is in clinical review and you did not build the case with caller can you reach out to an ump to finalize the case? What article would you follow?
Article: How do I handle a case status call?
No. Advise the case is open and pending review. Once the information is reviewed the prescriber/patient will be notified of case decision. The prescriber will be notified by fax, and patient will be contacted by phone.
What are the two places we check to see who handles the account and coverage review? What article would you follow?
Article: How do I identify who manages the coverage review?
Message Center and Drug Coverage Notes (DCN)
What must be included in documentation for CSP? What article do you follow?
Article: What are the best practices for case documentation?
CSP Documentation Must include:
Caller's First Name and Title or relationship to patient
Patient's First/Last Name
Medication name/strength
Medication quantity/day supply
Medication directions, if given
A brief summary of what took place on the call. (Example " Txfr to PCA")
What is a warm transfer and what is a cold transfer?
What article do you follow?
Article: How do I transfer a call?
A warm transfer is when an agent is calling the next advocate and giving all needed info before transferring the caller to the line. A cold transfer is when the agent is sending the caller over with having no interaction with the other advocate.
Provide the pieces of HIPPA/auth you collect for non-patient and patient level, and what article provides the information that can be used for verification?
Article: What is the verification hierarchy?
7 for Non Patient Level
Patient First Name
Patient Last Name
Requestor's First
Title/Relationship to patient
Drug Name
and 2 additional pieces of HIPPA
4 for Patient Level
Patient
Patient First name
Patient Last Name
and 2 additional pieces of HIPPA
When faxing out the ccq to the prescriber's office and a clinician has not reviewed the case, do you route the case to the clinician review workbasket? What article would you follow?
Yes.
Article: How do I fax the clinical criteria questions to a prescriber?
A. Check the Route to Clinician Review check box.
Notes:
If the Route to Clinician Review check box does not display, manually send the case for review. See: How do I send a case to Clinician review?
Only send initiated cases to Clinician Review See: When do I route a case to Clinician Review?
B. Click Fax Coverage Criteria
C. Click Submit
What do you do if there is no phone number listed in drug coverage notes to determine who handles the review for a primary case and BCR is needed, how do you find who manages the BCR? What article would you follow?
Article: How do I find out if Express Scripts handles the coverage review or appeal?
1. Access the patient's account in CSP. See: How do I search for a patient in CSP?
2. Select Benefits>Benefits Overview.
3. Scroll down to the Reviews & Appeals section.
4. Select the following in the Reviews and Appeals drop-down.
Administrative Appeals> Admin Appeals Case
1st level Administrative Appeals: Level 1 BCR case.
Always look for Express Scripts. If you see anything other than Express Scripts, we don't handle the review.
What caller code should be used for a parent or legal guardian calling on behalf of a minor child less than 18 years of age. What article do you follow?
Article: What Commercial Caller code do I use?
Phone: Patient
What do you advise the caller when warm transferring to another department, and what must you obtain and provide caller before transferring? What article do you follow?
Article: How do I transfer a call?
Caller must be provided with the amount of time they're being placed on hold, and agent must check back with caller if hold time is starting to exceed timeframe provided. Agent must also ask caller for a callback number prior to transfer and provide caller with the number to the department they're being transferred to.
Important: Do not give out internal phone numbers. See: CRD Complete Phone List.
What do you do when you receive a call that is transferred from an external and internal department, and what article do you follow?
Article: How do I handle a call that is transferred to me?
See if the call transferred to you is from an external caller or internal department.
External Caller
1. Give the monitoring disclosure statement. See: What is the monitoring disclosure statement?
Scripting: My name is <your name>. I would like to inform you this call may be monitored or recorded.
2. Authenticate the account. See How do I authenticate an account?
Able to Authenticate: Assist caller with the request.
Not able to Authenticate: See: I can't authenticate an account.
What do you do if an MA from the prescriber's office calls to request a peer to peer? What article would you follow?
Article: How do I handle a peer-to-peer request?
If there is a denied and locked primary case on file?
No: Inform that a P2P is only available for denied primary cases. If a new primary case is available, offer to build with the caller. Note: If there is an open appeal activity, provide case status. See: How do I handle a Case Status call?
Yes
A. Inform the caller that:
A P2P can only be completed by the prescriber who is on the denied case.
When prescriber calls in, they are immediately warm transferred to the clinician for the review.
B. Provide the date/time that the prescriber can call in for the P2P; Monday-Friday 7:00AM-8:00PM EST.
Note P2P requests cannot be scheduled, the prescriber must call in.
What if the prescriber's office is calling to backdate a case and the case is locked. What are your next steps, and what article do you follow?
Article: How do I backdate a case?
Contact RS, only a Resolution Specialist can backdate a case for an existing approval already on file.
What do you document when you are unable to complete the clinical questions? What article would you follow?
Article: How do I document a commercial case when I cannot complete the clinical criteria?
Document in CSP and OnePA
If an update is needed: Document a brief summary of what took place, case status, and next actions.
Phone: Document unable to complete.
If the criteria question states more documentation is required, add: Advised of <case#> and that documentation is needed.
If documentation is required, and caller states that they can't or won't send the documentation, add:
Advised of <case#> and that documentation is needed, caller doesn't have (or won't) send documentation.
Fax: Unable to complete.
Please provide the phone number for Centene call transfer for carrier ID 2EAA. What article do you follow?
Article: Medicaid Centene Contact Numbers
Internal Phone Number: 1(833)-236-6688
Phone Number to give callers: 1(800)-460-8988
What do you verify and update as needed if your caller is the prescriber, prescriber's office, or Pharmacy calling to check status of a case? What article do you follow?
Article: How do I handle a case status call?
Prescriber, Prescriber's office, or Pharmacy
A. Review the prescriber's information and update it as needed. See Prescriber Information Overview
B. Confirm the patient's phone number with the caller.
Note: Update the patient's phone number in the case, if applicable. See: How do I update the patient's phone number on an open or pended case in OnePA?
Patient, Representative (Personal or Appointed)
Confirm the patient's phone number with the caller.
Note: Update the patient's phone number in the case, if applicable. See: How do I update the patient's phone number on an open or pended case in OnePA?
What if you get a ccq that ask for specific documents and you're wondering if the type of docs the prescriber's office is saying they are sending are going to count / the prescriber's office already send documentation and they want to know why that documentation was not enough-- who in the phone book are you going to call ? What article would you follow?
CRD-RPH
Article: How do I consult a pharmacist?
What if a medication has a 70 not covered reject and additional reject message states that member must engage with Omada Health or Teladoc, what do you advise the caller?
Article: Evernorth EncircleRx Cardiodiabesity Program Reference
Advise caller that member must engage with either Omada or Teladoc based on the additional reject message.
Omada Health Phone number: 1(888)-409-8687
Teladoc Phone number: 1(800)-Teladoc (1-800-835-2362
When giving the case outcome to a prescriber's office or patient what verbal decision drop-down is used and what is the disposition? What article do you follow?
Article: How do I create a case log for verbal notification?
Create a case log in OnePA.
In the verbal decision notification drop-down select one of the following:
Attempted/Patient notification for patient
Caller Code: Patient
Reason Code: Notification
Medium: Manual Outbound
Attempted/Physician notification for physician
Caller Code: Doctor's Office
Reason Code: Notification
Medium: Manual Outbound
Direction Code:
In: Inbound
Out: Outbound
Disposition: Live Answer/Xfer to CSR
What is the phone number for CRD Vendor Restricted Accounts? Is this a cold or warm transfer?
Bonus: There are 2 articles for this question.
What articles would you follow?
Article: CRD Complete Phone List
How do I transfer client and member restricted accounts?
Phone number: 1(800)-351-0586
Warm transfer
What's a patient level requester and non patient level requester? What article would you use?
Article: What is a patient versus a non patient level requester?
Patient Level Requester
Patient, Appointed Representative, Authorized Appointment of Representative (AOR), Parent or legal guardian for person less than 18 years of age. (Verify the parent/legal guardian is listed on the account), Personal Representative (Caregiver), or Patient provides verbal permission during the call for the person to speak on their behalf. (Case log must be created in OnePA with documentation of the name and relationship of the person that has permission to speak on their behalf. Indicate patient gave you verbal permission to speak with the caller. Treat the request as though the patient is requesting review. Select Patient as the caller code.
Important: For Appointed Representative, AOR and Personal Representative (Caregiver):
Verify the person is listed on the account.
Go to Profile tab in CSP
Non-Patient Level Requester
Client or Internal Express Scripts (Example: Account Management), Spouse or other family member, member of the household/other caregiver, Prescriber's office staff, Retail pharmacy staff, Third-party requester
Important: If a patient gives verbal permission, the caller becomes a patient level requester.
What do you do if you have a caller that is not prescriber office or pharmacy staff requesting temporary coverage for a medication, and a case is needed and cannot be completed? What article would you follow?
Article: How do I consult a pharmacist?
Temporary Coverage Override needed
Not the pharmacy/prescriber's office
A. Confirm the prescriber's office is closed via outbound call (regardless of office hours).
B. Go to Step 2 of the article.
Ask the caller to hold two or three minutes while you get a pharmacist on the line.
Notes:
For UMP or PC RPH hours and phone number, See the UMP section in CRD Complete Phone List.
If you lose the caller while contacting the pharmacist, follow the steps in the article based on how the call disconnected.
What do you do if a prescriber is the patient calling to request a PA? What article do you follow?
Article: Clinical Criteria Question Guide
Patient is Prescriber:
Build the case and move the case to Clinician Review. See: How do I create and complete a phone request for coverage review?
How do I create and complete a fax request for coverage review?
Phone: Reach out to an UMP to review.
Add a case log in OnePA to document indicating the prescriber is the patient or immediate family member.
Where and what do you document when there are no cases on file, and we don't handle the account? What article do you follow?
Article: What are the best practices for case documentation?
Document in CSP: No cases on file, account not handled by ESI, and caller was transferred to client.
When making a transfer to Clinical Appeals or BCR is this a warm or cold transfer? What do you do if a caller is calling outside of normal business hours?
Bonus: There are 2 articles for this question.
What articles do you follow?
Article: How do I transfer a call to BCR or Clinical Appeals?
CRD Complete Phone List