Medicare Part B EOC Phone Request
You should enter ______, _______, and _______, in the ‘Directions’ box?
The dose per visit, frequency, and visits (if provided)
After reviewing all pages of the fax, you are unable to verify the frequency. How should you proceed?
Leave the Directions field blank and document why the information could not be provided in the comments on the review page. You do not need to make an outbound call to get the frequency.
When you receive the IPA pop-up in PA Hub, where do you verify who is responsible for the review?
GBD Facets – Delegated Risk screen
Providers have the right to appeal a denial within ___ days of the original organizational determination
60 days
The doctor office is requesting a retro review for a drug they already administered to the member. What do you tell them?
Please submit clinical documentation requesting a retro review along with the claim through the normal claims submission process.
On the Additional Information tab, you should always select either Prescriber or Pharmacy as the requestor, true or false?
False. You should never select Pharmacy as the Requestor.
The fax must provide the 'Number of Visits' or we cannot create the case? It is required to put in the direction box and comments box. True or false?
False. If provided, enter the number of visits in the directions box ONLY. The RPh will determine the number of visits when completing their review. No OBC is required
After reviewing ePA details and supporting documents, you were not able to locate a diagnosis. Your OBC was unsuccessful. How should you proceed?
Type the default diagnosis code R69 and add a note to explain why this was selected. Continue processing and document at the end of the case.
If the request is for the same drug, different dose, same provider and a previously denied Part B case is on file within 60 days of the original determination what do you do?
Build a new EOC and submit for RPh review
Would a Nurse Practitioner be allowed to write a prescription?
Yes, a Nurse Practitioner is allowed to write prescriptions
If CVS Specialty Pharmacy will mail the medication to the member and the nurse from and Infusion Center will go to the member's home and administer. What will the Dispensing Location be?
Home
If you receive a fax for Oxycodone 10mg tablet and the member plan is MA only, what should you do?
Send the fax back to the requestor and advise to contact the member's pharmacy benefits
If the IPA pop-up says, "Part B reviews for this member may be the responsibility of the IPA. Select the appropriate option to continue." Is the review the responsibility of the IRx, true or false?
False. The review is responsibility of the IPA
You can rebuild a denied case for a pharmacist to review if a denial was given more than 60 days ago, true or false?
True.
What is the job of Right Drug Right Channel (RDRC) in PAHub?
Steer self-injectable drugs down pharmacy and injectables that require a healthcare profession to administer down the medical path.
If PLUTO is showing pre-certification is not required for a drug but the prescriber is insisting on a pre-determination, what do you do?
Select 'Pre-Cert Required - Continue Building EOC' to continue building case and document in case requestor wants pre-determination
What are the steps when you receive a Part D to Part B fax?
Check EOC history to identify the Part D case and make sure there isn’t a Part B case already built for the request.
Check to see if the department for Part D in EOC history says Carelon
Open the full report from the Part D case and use that information to build a case for Part B
What is one thing you MUST do for every Part B ePA case?
MUST reselect the member THEN reselect the drug for ALL Part B ePA cases from both the ePA Intake and ePA Pre-Intake Queues to ensure the case is built under Part B.
You receive a fax with additional information to a denied case. You see the information was submitted before the denial but was not attached. What do you do?
Rebuild the case. Create a new case.
Janet called to submit a precertification for Avastin C925. Services are being rendered in Alaska. How should you proceed?
Advise caller the correct code for Alaska is J7999 and that no pre-certification is required.
According to the SRx drug list, what is the J code for Denosumad and is CarelonRx responsible for reviewing?
J0897; yes, CarelonRx is responsible
You receive a fax request for a Arizona member LOB is Medicare for J0897 to treat cervical cancer (C53. 9). How should you proceed if LOB is Medicare?
Build the case. AIM does not review for this plan.
Why would something land in the ePA Pre-Intake Queue?
If any of the required items (member, requesting prescriber, or health care service details) do not match between ICR and PAHub, they will land in the ePA Pre-Intake Queue
If the denial was given only because a non-preferred drug was requested, and the provider is now requesting a preferred drug be used, they must file an appeal. True or False?
False. A new case must be built and sent for RPh review
When working a fax, the prescriber comes up as Out of Network. You check Sam.gov and find an exclusion. What do you do next?
Make an outbound call (OBC) attempt to inform the provider they have opted-out of the Medicare network. Ask if they would like to continue with the review or withdraw the request. Document the outcome of the call in the case.
If the provider would like to continue with the opted-out provider, the associate will document findings from the Opt-Out List search and the provider was advised and requested to continue with the case and send to the Pharmacist for review; the case will be reviewed as a denial
If the OBC is unsuccessful, associates will continue submitting the case with the opted-out provider and document findings from the Opt-Out List search in the case. Send to the Pharmacist for review; the case will be reviewed as a denial.