Major Medical Verification
SPRx Benefits Verification Major Medical Verification source document number.
What is 013366?
Specialty Benefits Verification Availity User Guide source document number.
What is 010820?
Specialty Benefits Verification UHC Portal Guide source document number.
What is 074655?
SPRx Benefits Verification - MedCompass source document number.
What is 075698?
SPRx Payor File Search Feature source document number.
What is 051805.
This process requires handling claims as primary under major medical, limiting the supply to 30 days, and completing additional verification steps due to the absence of electronic claim details.
What is the MAJ claims process using manual paper billing (Non-ECS)?
Users can access the Eligibility and Benefits Inquiry screen through these two menu locations, both tied to patient registration navigation.
What are the Patient Registration menu on the left and the My Top Applications section?
When a prior authorization is already on file, this validation process ensures alignment of pharmacy details, drug specifications, authorization dates, and place of service before proceeding, including using a specific reference number format when available.
What is verifying an existing prior authorization?
After locating a member record, this workflow step involves selecting a hyperlink to access the Health Summary page and using a specific menu to review areas like Utilization Management, Insurance, and Activities.This action from My Dashboard gives you access to the Member Search page, where entering patient details will generate a list of matching records and active plans.
What is clicking the member’s name and using the left navigation menu?
The main goal of using all available search criteria in the Payor Search window is to complete this action accurately.
What is locating the correct payer file?
When handling a new patient, new insurance, or a new plan year, agents should first challenge this type of coverage and, if denied, take the extra step of contacting the plan to confirm the drug is not eligible.
What are Rx benefits?
When searching for an MAJ without an alpha prefix, this adjustment allows successful lookup when using a CarelonRx ID or when working outside of national policy requirements.
What is removing the last two digits and the alpha prefix when applicable?
This review requires confirming dispensing pharmacy alignment, matching NDC and day supply to the prescription, validating service location, and ensuring the authorization dates apply, often using a reference number beginning with a specific letter.
What is validating a prior authorization using the PA reference number (beginning with “A”)?
When using this type of search, entering only numeric values without hyphens can take you directly to the associated service authorization instead of displaying a list of results.
What is the Authorization Reference Number?
When multiple bill groups exist within a Payor File, this item will not appear in the search results, requiring you to open the file for more details.
What is the Bill Group?
When a medication is covered under the pharmacy benefit but an approved prior authorization exists under the medical benefit, this process requires contacting the medical plan to confirm coverage scenarios and determine next steps based on how the therapy is administered.
What is verifying dual coverage?
Failure to select this correctly in the top-right drop-down can result in inaccurate benefit and eligibility information being displayed.
What is the patient’s home plan state?
When verifying whether a PA is required, this process includes confirming pharmacy alignment, matching drug and prescription details, validating authorization dates, and adjusting key identifiers if no information appears under the initial search criteria.
What is verifying prior authorization requirements and switching Tax ID if needed?
This navigation method provides access to tiles displaying pending, denied, and approved authorizations, where selecting a tile reveals detailed authorization information.
What is accessing the Utilization Management page from the left navigation menu?
On the Insurance and Dispense Maintenance screens, this interactive feature allows users to access Payor Search details, where the outcome differs depending on whether one or multiple matches exist.
What is the Bill Group hyperlink?
We contact the Payor to validate these details before updating the PA screen.
What is the following details?
MDO listed (If new RX received for same drug)
NDC or Drug name/Strength
Number of fills and or Units remaining
NPI listed on PA matches dispensing pharmacy.
Confirm Effective and Expiration dates of PA.
This tab displays the coinsurance percentage for a specific benefit and may include a Utilization Management phone number, but agents must not rely on the presence or absence of that number to determine authorization requirements.
What is the Coverage and Benefits tab?
If no results populate during PA verification, this corrective step, along with validating pharmacy details, NDC, quantity, day supply, and authorization dates, ensures accurate determination of PA requirements.
What is switching to the Monroeville Tax ID and completing full PA validation?
While reviewing a service authorization, these key data points must be validated to confirm accuracy and alignment with the patient’s coverage and therapy details.
What are the Reference Number, Authorization Type, Authorization Status, Line of Business, and Effective Date?
BONUS QUESTION
Before initiating a PA through CMM, failure to identify limitations within this section of the payor file could result in an invalid submission or missed escalation path.
What is checking the payor file for restrictions before initiating a PA?