Tools
CVS Caremark Prior Authorization system used to submit and check SGM PA status.
What is CAS?
SGM (CAS) PA Help Line
What is 1-866-814-5506?
We are filling a quantity and/or day supply over the plan's set limits for product dispensing.
What is M/I Day Supply?
The source document TSRC-PROD-014697.
What is Specialty Benefits Verification Talk Track Scenarios?
This edit failure appears when…there is a Manufacturer PAP Card MAJ bill code loaded on to the patient’s insurance profile but no valid MOP linked to the bill group.
What is PAP card found?
Centralized CVS Specialty Pharmacy Information Reference tool.
What is Pharmacy Reference?
The AI summarizes relevant information from all note categories (excludes Rx note category) and Action History into a concise, easy to read format.
What is Note Summary?
Anything under or over the plan limits will create this rejection including excess quantity, day supply, drug cost submitted, and refill interval or utilization requirements.
What is Plan Limitation Exceeded?
Source Document TSRC-PROD-022675.
What is SPRx Task Contact Frequency, Max Attempts, and Descriptions?
This edit failure appears when…there is a potential error with the prescription entered or when a Medicare plan has limited the amount of refills per prescription and a new prescription is needed.
What is Refills Exceeded?
Locate patients that have CVS Health as their Pharmacy Benefit Manager. Provides eligibility, prescription plan design and processing information, override and PA details, demographics, prescription history, as well as other client related details.
What is Peoplesafe?
Is available only on PA tasks and assists with next steps in the PA process per procedures listed in theSource.
What is PA Guided Workflow?
This task is commonly associated with the following ECS rejections for NEW patients: Filled After Coverage Expired, Filled After Coverage Terminated, and sometimes Non-Matched Cardholder ID, M/I Cardholder ID or M/I Group Number
Insurance Needed Task
Document number for SPRx Benefits Verification Process.
What is Source Document TSRC-PROD-013375?
This edit failure appears when…the business unit being processed is most likely not contracted with the insurance.
What is restricted payer?
HUB for Specialty Work Instructions and Job Aids.
What is the Source?
When initiating a PA, if the Rx is enrolled in Specialty Expedite and all information for the PA request is completed, we should do this.
Submit the PA request to the insurance and select Action: PA Started/ Outcome: Sent to Insurance.
The prescription serial number is invalid or missing from the Rx.
What is M/I Scheduled Prescription ID Num?
Document number for SPRx Benefits Verification PrudentRx Copay Optimization Program.
What is Source Document TSRC-PROD-031083?
This edit failure appears when… no ICD code or an invalid ICD code is present on the patient profile that is not covered by the Major Medical Payor.
What is ICD PAT check?
Access to electronic health records for enrolled providers that can be utilized to request PA's on their behalf.
What is Data Viewer (EHR)?
In the Data Viewer, if the Referring Prescriber's Expedite Status is displayed as "not enrolled", it can still be used for this.
What is clarifications?
Indicates the claim did not make it to the PBM and task should be pended for the same day, within 1 hour.
What is Host Not Available?
Document number for Specialty Benefits Verification Common Rejections and Solutions.
What is Source Document TSRC-PROD-016073?
This edit failure appears most commonly when an NDC Change is needed for a Biosimilar.
What is DNF Non-Preferred?