Verify Drug Benefit
It is referred as the date a drug being dispensed.
Date of Fill (DOF)
This is called a medication approval process.
Prior Authorization
Yeheyyyyyyyyyyyyyyyyy
Your team acquires 20,000 points.
This means the prior authorization process has started. HCPR is awaiting medical records to complete the review.
New Request
What is the expedited time frame of prior authorization?
24 Hours
It refers to the amount and frequency a medication is taken at one time.
Dosage
Who can initiate a prior authorization?
Member or Doctor
(Fill in the blank): When a prior authorization is approved, letters are mailed to the member and the physician. Members also receive a ____________________ message within 72 hours of approval.
Voice Automated Technology (VAT)
(True or False): When the Outcome field shows Denied, inform members the medication is denied and can be filled at a participating pharmacy. Relay the approved duration shown in the Outcome Verbiage.
False
If the outcome shows EOC Aborted, what do you need to advise to the member?
Advise the member that HCPR did not receive the requested information from the doctor, and offer to start a new request.
Power to Deduct
Remove points ranging from 1000 to 5000 points on your selected group.
Hep Hep Hooray!!!
Your Team receives 50,000 points from Discaya.
(True or False): If a prior authorization is rejected, HCPR mails a letter informing members of the denial including guidance on seeking alternatives from their doctor and their appeal rights.
True
Thank you for your generosity.
All teams will receive 20,000 points.
Authority to Add Points
You can allocate points to your group as well as to other groups, with amounts ranging from 15,000 to 30,000 points.
This Classification and intent are used when providing RX benefits provided for a prescription
TRIGGERS:
How much does this medication cost?
Classification: Rx
Intent: Benefits and Copayments
It's a request for Humana to decide whether a medication should be covered or covered at a lower tier so members know what their cost will be.
Coverage Determination
Authorization in RX Nova is categorized into four types. What are they?
Pre-Auth, Restricted, Customized, and Clinical
(True or False): Once the authorization denied Offer to locate covered alternatives in RxConnect the member can discuss with their doctor that do not require prior authorization. If the caller is not satisfied with the decision, they can file an appeal.
True
When handling Prior authorization status. What is the Classification and Intent used?
Classification: Rx
Intent: Authorization
(Fill in the blank): ________ refers to the concentration or potency of the active ingredient in a medication. Typically, the higher the ____________, the higher the cost.
Medication Strength / Strength
These are healthcare professionals who review coverage determination requests specifically for prescription medications.
HCPR "aka clinical department"
BOMB!
Your team will have 10,000 points deducted.
What is the standard timeframe for coverage determination?
72 hours
What is the mentor article used to determine if Prior Authorization is needed?
Determine if Prior Authorization is Needed