General
What we input for the patient's date of birth when manually driving the IVR for BCBS of Texas, Oklahoma, Illinois, New Mexico, or Idaho so that we will get routed to an agent.
What is today's date?
IVR Tips and Tricks
Our next steps when the plan is secondary and the agent cannot explain how the plan coordinates benefits after pushbacks.
What is escalate to a supervisor at the end of the call? GNE Q&A Line 115
The prior authorization status that we input when an agent provides today's date as the end date for a PA on file and there is no other active one.
What is Expired? GNE Q&A Line 264
The pushback we use when an Aetna agent states they cannot lookup benefits by codes.
What is "Can you look up by description?" GNE MM Q&A Line 210
The task note(s) we add when an agent states no other insurance is on file and the COB was last updated 2 months ago.
What is "COB has not been updated recently. Please advise patient to call insurance company."?
GNE MM Q&A Line 104
The number of attempts we at least need to make if an Aetna agent states, "I cannot proceed without a tax ID," and will not proceed after the NPI is provided.
What is two attempts?
GNE MM Q&A Line 14
The network status for an Indemnity Plan.
What is In Network? GNE MM Q&A Line 30
What we input for admin code PA requirements when the J code is locked YES and an Aetna agent will not give the PA requirement for the admin code(s).
What is "No"? SOP Updates
Our input for "Is a referral required to see a specialist?" when the agent answers the question incorrectly or cannot confirm, even after pushbacks. There is no PBV/PIE.
What is Headset? GRAS/Lucentis/Ocrevus Cheat Sheet
The task noteee when an agent states that both a Prior Authorization AND Pre-D are Required.
What is "Predetermination required for {J code/admin} code. Contact {Name} Department at {Phone Number}."?
Task Notes tab in GNE Q&A
Our input for "Does the plan/payer administer the Medicaid or does the state?" in this scenario: The agent cannot answer. The plan pays 100%, and we pushed back to to confirm that the patient does NOT have any financial responsibility for the J code, admin code(s), and specialist office visit charges.
What is "Plan/Payer"?
GNE Q&A Line 161
The pushback we use if a Humana agent states that the provider/practice is Out of Network for a Medicare Supplement plan.
What is Free Text: As long as the provider accepts medicare assignment would they be in network?
GNE MM Q&A Line 33
Our next steps when we try to transfer to the prior authorization department and an agent states that they are part of the prior authorization department.
What is gracefully exit and verify PA info with another agent? SOP Updates
The pushback and input we use when an agent cannot determine if there is any other insurance on file or if the plan is primary.
BONUS 100: The task note(s) we add in this scenario.
What is "Can I have the benefits as if you are the primary provider?", Headset, and skip all subsequent questions pertaining to other insurance?
BONUS 100: What is "COB has not been updated recently. Please advise patient to call insurance company."?
GNE MM Q&A Line 105 - 106
The task note(s) we must add when an agent states they cannot give benefits for the J code because they are only covered by Prime Therapeutics.
What is "Services are covered by Pharmacy Benefit Manager; contact Prime Therapeutics at {Phone Number}."?
GNE Q&A Line 156
Task Notes tab in GNE Q&A
The prior authorization status that we input when an agent states the PA on file has a 2 month old end date and there is no other active one. There is No PBV/PIE for PA on file.
What is "Not on File"? GNE MM Q&A Line 225
The network status and type of benefits we collect in this scenario: A BCBS agent on an Ocrevus call cannot check the network status of the practice. The patient has out of network benefits.
What is Unknown(Collecting IN and OUT)? GNE MM Q&A Line 43
What we input for this scenario: We ask if buy and bill is available. The agent states the physician must buy and bill through Prime Therapeutics and does NOT change their answer after a pushback. There is no PIE/PBV.
What is Buy and Bill not available and Specialty Pharmarcy is Required: Alliance Rx Walgreens? GNE Q&A MM Line 300
Whether or not we are able to heaset when an agent does not understand the question, "Does the specialist office copay apply regardless of whether an office visit is billed or not?" or "If the office visit is not billed, does the patient still owe the specialist office copay?".
BONUS 100: What we input for this question if the admin code copay and SOV copay are the same.
What is do not headset?
BONUS 100: What is "Yes"?
GNE Q&A Line 201
The task note(s) we use when we escalate to the PA department for step therapy, but we get transferred to several departments and agents cannot confirm if step therapy is required.
What is "Prior Authorization Department escalation results in no answer for step therapy."?
Task Notes tab in GNE Q&A
The name of the default Prior Authorization Department for BCBS of Massachusetts.
What is Clinical Pharmacy? BCBS of MA Cheat Sheet (GNE)
The input for "How does this plan coordinate benefits?" COB when a GHI PPO plan is secondary to Medicare.
What is Supplement? SOP Updates
Our next steps when the J code PA requirement question is not locked, an Aetna agent answers "Yes" for the J code, and the agent says to call a different department for the admin code PA requirements. BONUS 100: The task note we add when J code and admin code is handled by different parties.
What is an escalation? Bonus: What is "Prior authorization for the administration code is handled by the {Department name}: {Department number}."? SOP Updates
Our next steps for an Ocrevus call when a BCBS agent refuses to provide a fax number for the Prior Authorization Department and states that a prior authorization form is ONLY available on the provider portal. PBV shows "Yes" to PA form available and includes the PA website URL, but PBV does NOT include a PA fax number.
What is escalation for PA fax number?
GNE Q&A Line 250 and 255
The task note(s) we must add on a BCBS call when the provider's state is different from the BCBS state/region we collect benefits from. Example: We try Empire BCBS, then the Blue line, then get transferred to BCBS Texas where we get all of the benefit information from.
What is "Plan administered by third party; contact: {Phone Number}." and "The local BCBS Specialty Pharmacy will be determined upon approval"?
SOP Updates
GNE MM Q&A Line 286-287