Reject Codes
This medication requires your doctor to obtain prior authorization from us in order to be covered through the pharmacy benefit. Includes Step Therapy and New to Market.
What is a 75 rejection?
The 3 pieces (ID, Name, DOB) of information to verify the member.
What is Member's HIPAA?
The status to review a fax request.
What is Incomplete?
The action button that will take you back to the Home page. Case will be unassigned from you. You should only use this when the case is completed or sent to Clinical Review.
What is the Return button?
Requesting 4 pens per month. Inject 0.75ML every week. Package size 0.75ML. What is the quantity per 30 days?
What is 3ML per 30 days?
Non-Formulary medication that providers can request for an exception.
What is a 70/MR rejection?
Running a test claim using the same medication, same date, same quantity, and same pharmacy using the T action.
What is a Quick Test Claim?
The status to review an EPA case.
What is Tech Review?
The case should be sent to this status when the medication is for a formulary exception or quantity limit, or clinical information of the PA did not meet the criteria. Analyst cannot approve the case.
What is Clinical Review status?
Requesting 0.40ML syringe every week. Package size 1 EA. What is the quantity per 30 days?
What is 4 syringes per 30 days?
This medication has quantity and dosage limits that are recommended by the Food and Drug Administration (FDA). The quantity exceeds these limits.
What is a 76 rejection?
Used to search a medication's NDC and package size.
What is Drug Search?
The action button that will move the case into the next status.
What is the Submit button?
How would you process a case that is a Weight Loss Excluded group?
What is Admin Deny BE (Benefit Exclusion)?
Requesting 12 cans monthly. Package size 237GM. What is the quantity per 30 days?
What is 2,844GM per 30 days?
Refill too soon
What is a 79 rejection?
This can identify if a member has a BCBS formulary or Standard Control (Template) formulary.
What is the Carrier ID?
How to process a medication when claims are paying, it's a City of Boston account, and the medication normally requires a PA or Step Therapy that is not a specialty medication.
What is No PA?
When a case has been approved, the analyst must check that the claim is now paying and correct letters are generated. (True or False)
True
2 syringes per month. Package size 1.17ML. What is the quantity per 30 days?
What is 2.34ML per 30 days?
A non-contracted pharmacy is dispensing a specialty medication.
What is a R6 rejection?
Member's formulary when their Carrier ID is NOT 22MC, 22MG, 22ND, 22MY, 22MZ
What is the BCBS Formulary?
When there is a Denied case within 180 days for the same member, same medication, same prescriber, and new clinical information.
What is an Appeal?
When a medication must be dispensed by a contracted specialty pharmacy, there is a drop down that must be selected.
What is CVS Specialty?
1 capsule PO QD. Package size 100 EA. What is the quantity per 30 days?
What is 30 capsules per 30 days?