Missing Matrix Matters
Name the three fields in Section 1:Patient Information (adult) required for all services (LCBV, No BV, Copay, IT, an Sharps)?
What is Patient Full Name, Patient DOB, and Full Address (no PO Boxes).
Can we accept a prescription without a date?
What is no, HCP signature and date are required for valid prescription.
The HIPAA Signature Date is blank. What can substitute for it before you open an MI case?
What is the HCP Attestation date.
State two services that can be provided without HIPAA on file.
What is Sharps and IT
If you complete the Missing Information task as completed resolved/unresolved for third attempt, does that close the Missing Information Case automatically?
Missing Information Case must be manually closed with appropriate outcome after final task has been completed. Even if it closes automatically, PAS must double check for correctness.
On the Missing Information Matrix, what do "X", "O", and "N/A" each mean — and what's assumed about a field that isn't listed on the grid at all?
X-Required
O-Optional
N/A Not applicable
Anything not listed is assumed optional
Name three ways we can obtain the providers NPI.
What is on the enrollment form, verbally from HCP, or NPI registry? https://npiregistry.cms.hhs.gov/search
The HIPAA signature-block DOB is blank or entered incorrectly. What happens, and when does it escalate to MI?
Section 1 DOB is used instead; it becomes MI only if the Section 1 DOB is also missing.
Esign was completed with patient while on the phone, but hasn't been added to the patient record yet. How would you close the MI Task Attempt #2 and MI Case?
Task: Completed/Unresolved
Case: Open in progress since MI has not actually been rec'd.
No insurance was provided for a Lilly BV on the enrollment form. Explain the next steps to move the patient journey forward.
What is put in dummy insurance and run eBV. If nothing pulls, then open MI to obtain patient Rx insurance.
This service is the only one on the matrix that requires patient email as an "X," because a vendor's direct-to-address system demands it.
What is Sharps Disposal
Name 2 different valid acceptable Rx's on the enrollment form?
Initial dose (no samples or 1 sample), induction dose, Maintenance
Initial Dose (2 samples given), induction
Induction dose only (verified with HCP)
Induction and maintenance
Name the four acceptable methods of obtaining the Patient HIPAA Authorization
What are e-Sign on demand, API/ESG/WEP, verbal from the patient, and the HCP Enrollment Form?
A benefits investigation alone cannot confirm this Savings Program eligibility requirement; the box must be checked or the patient must verbally attest.
What is no government-funded insurance?
Name the process where an entire case is reviewed for quality assurance prior to moving the patient journey forward.
What is PSQA?
Under Patient Services 1. Savings card box is not checked, but the government attestation and T&C boxes are. Is this considered Missing Information and explain your answer.
What is not Missing Information, if the top Savings Card box is not check, then we treat it as if no savings card was requested.
Provider section is missing the following information: Address (including city, state, zip), Site/facility name, phone number and fax number. Per SOP USCIQ-TL-551-001-003 Missing Information(v6.0) (hint, hint) which items can be obtained from other documents included with the enrollment form submission? (example: cover sheet, clinical notes, patient demographics, etc...)?
What is Site/Facility name; Address, city, state, zip; phone number; and fax.
A HIPAA authorization arrives for a 12-year-old patient. The SIGN field is signed by the patient's mother, but the Authorized Representative Name, DOB, and Relationship to Patient fields in Section 1 are all blank. Is the enrollment clear to process? Explain what's required and what the agent must do.
No — this is Missing Information. For patients under 18, the Authorized Representative section is required (it's an "X" across all five services), so blank Name, DOB, and Relationship fields trigger MI even though the HIPAA signature itself is present. The Authorized Representative is the correct signer for a minor, but once identified the agent must also create an Association record (Role: Auth Rep, Caregiver, etc.) linking them to the patient. Note too that if the Auth Rep DOB in the signature block is blank or wrong, the Section 1 DOB can satisfy it automatically — but only if that Section 1 DOB is present; otherwise it's MI as well.
Section 4: Diagnosis is received with the 'L20.89' box checked, in addition to the other 'ICD-10-CM Code' with L30.0 written on the line. Is this Missing Information? Explain your answer.
State the cadence for missing information with a patient.
Attempt 1 -text,email,call (in that order with pt consent);
Attempt 2 – call
Attempt 3- text or email (if call only, DO NOT MAKE A CALL) close task as completed/unresolved task. Then close MI case as LTFU. Send Case closed fax to HCP
A pediatric enrollment arrives for a Lilly Conducted BV: the Section 1 DOB is blank, the signature-block DOB is blank, both device-type boxes are checked, and only the Induction dose is selected. Identify every one of these four conditions that constitutes Missing Information — and the one that does not.
What is: Section 1 DOB (MI), signature-block DOB (MI, because Section 1 DOB is also missing and can't back-fill it), and Device Type (MI — exactly one box must be checked); while Induction-only is not MI, since at least one of Induction or Maintenance satisfies the rule — though it should be confirmed with the HCP.
HCP requested SPBI with a valid HIPAA and HCP attestation. Copay card has been requested with all three attestation boxes checked. You notice on the Rx that two 'Initial' doses have been selected, 'Induction' dose skipped, and 'Maintenance Option B' selected. Can a copay card be assigned?
No, an MI case would need to be opened due to off-label dosing. Regardless of it being an SPBI, it is considered a deviation to assign a copay card before on-label dosing is obtained.
Adult HIPAA signature block has 4 parts - signature, today's date, printed name, and DOB. By field, please indicate what is required, what can be taken from other parts of the form and where, and what is optional.
Signature - wet signature required by patient; this can be esign, verbal HIPAA, API/ESG/WEG. A mark on the EF counts as a signature (this does not include copy and pasted signatures).
Today's date - if blank, HCP attestation date can be used. Can not be a future date, patient birthday, and considered a valid date.
Printed name: if blank, it's acceptable. If name is written, it must match exactly a name on the enrollment form.
DOB -if blank or incorrect, can use DOB from section 1.
A form arrives with the Specialty Pharmacy Conducted BV box checked but no SP name or phone, and the Lilly Conducted BV box blank. Explain why this is not Missing Information, and name one condition under which the BV checkboxes would trigger MI.
What is that SP name and phone are not required even when that box is checked — and MI triggers only when neither of the two BV checkboxes or both are selected?
Name two items that trigger MI for Lilly Conducted Benefits Investigation, but agents can move forward completing the BV, rather than stopping the case.
What is patient phone number and copay attestation.