Test Claims
What information may we need to run a test claim?
Name of the medication> Strength/dosage info if known> if they are going to do mail order delivery or what pharmacy they are picking up from?
What are some reasons a member may need a prior authorization?
-non-formulary drug
- denied test claim (PA required) for formulary drug
If the next fill date is within ____ days , the order goes to into Future Fill and begins processing on that date.
14 days.
per the source
if a member is wanting to make a payment using a Credit Card how would you assist?
warm tran mm to SRT to have card info input.
A new member calls in to have his rx transfered from Humana to CVS Caremark, Mail Order Delivery, what is the first step to assisting the member?
-check if they have already been entered into our system/ if not then advise that we can request for the medication with a new rx... verify the drug, name, dosage and strength and provider.
what steps do you take in compass to run a test claim?
compass>claims tab>create test claim
Where do you go to check the status of a PA?
compass>claims landing page>Overide/PA history
These orders cannot be filled through this process and require a warm transfer to where?
Specialty Medications
transfer to specialty customer care
memeber is calling due to cost of medication is higher than they can afford, what options can we offer for the member?
M3P, tier exception, Benelynk for LIS, etc....
We can not transfer a members prescription if____?
it is expired or has no remaining refills.
If a test claim is denied, where should you look to see denial reasons?
Reject Code Hyperlink
If you determine that a PA has been denied, what is the next steps
member and/or provider has the option to submit and appeal/redeermination
if there are no available refills and RX has expired , what steps would you take?
bonus: what information would you need to obtain?
Initiate a new RX request for the medication.
verify name and dosage information for medication, verify the provider, verify that the mm is still receiving this medication through MOD.
The member is calling to make a payment for his precription payment plan. How can you assist with this?
Compass> member snap shot> quick actions> M3P>payment
if the member is using a cc , we must transfer to SRT.
Tammy called in due to running out of medication sooner than she expected, how do you proceed to assist her with her refill request?
you will need to enter an early refill override.
compass>claims>mail rx> select the rx and click early refill.
This disclaimer must be read when giving estimated cost of test claims or coverage information
“Please note the prices quoted are estimates and may not reflect your actual out of pocket costs”?
What is the turn around time for a standard PA and Expedited PA
Expedited PA(CD)-24 hours
Standard PA(CD)- 72 hours.
Bonus: Do these times includes nights, weekends, and holidays? true of false?
What is the steps you would take to process a refill order?
compass> verify the correct medication name and dosage/strength.
if you see partial authorization for MOD payment this means?
that only partial payment was received, mm will need to provide payment for remainder balance due
1 per year, per drug
if a test claim is denied, what steps do you take to further assist the member?
educate on denial reason> review alteratives> advise if a PA is needed, offer to submit PA> educate mm on the TAT.
What do you do if the member has paid out of pocket prior to PA(CD) approval?
-advise the member that they can submit a reimbursment claim by submitting a paper claim
the form is located in compass> quick actions panel >member resources
can also be located on member website.
When a caller is authenticated but calling on someone else’s behalf, they must provide one of these two items before a refill can be processed.
Rx number or Rx name?
“My card is fine—why didn’t it work?” System shows Expired/Invalid/Denied Auth—what do you tell them?
The method of payment requires an update
advise the member of the ship consent needing for her refill
mail rx tab> Click the appropriate checkbox(es) for prescriptions marked for Ship Consent Hold.>Add to Selected Rx(s)>Click the Refill/Renewal button. >Ensure that the prescription name, strength, form (tab/cap, etc.), quantity & days’ supply is correct > select ship now.