So you want to be a CAC

PNL Codes

100

PPO/OP/31830

Follow the No Review Required Process

200

OPF/49505/PPO/KY

Reroute to SOS

300

PPO/J0485/OP

Send to Drug Team MNRPARTBSTAN

400

PPO/80162/Unable to speak with provider 

Check the business process and follow the current rules.

500

PPO/IP/00540/99337/27447 

27447 is red on the PNL & this is a red code. You need to run Addendum E and should find that is it not on the IP only list. You must document the LOC macro and attempt to call the provider to switch the case to OPF.

Types of cases

100

PPO INN Home Health - Member is currently IP

Approve as member is IP. No SOC or script needed

200

HMO/OON/99214/Previous gap on file

Approve per previous gap matching previous end date

300

Transportation- 55 miles

Ping/Email Angela for OK to approve

400

SFL DME OON Company

Call/email MedCare and confirm if they carry the item

500

SFL MedCare DME 2nd Item

Route to RN notating “Per provider, This is a second item for this member.”

Macros

100

Provider Ask to Cancel Case

Run the Withdrawal Macro

200

Gap case admin denied

Gap Denial Macro

300

Provider Request Expedite

Run Upgrade to expedited email template and add to email to NCPA

400

Day 11 Clinical Denial

Decision Communication Macro

500

Day 5 Clinical Denial

Pre-P2P Outreach

PNL codes 2

100

PPO/66982

Call provider to confirm if procedure is related to lasik. If yes send for review, if no admin approve/withdraw. If unable to obtain by day 6 send for review.

200

SFL/E2311/MedCare only Fee for service

Get clinical send for review no need to check fee schedule

300

SFL/MedCare/B4149

Per your SFL notes ALL nutritional codes go for review

400

PPO/E0676

Deny per the Non-Covered List

500

PPO/A6538/PLAN: KEN 15725

Check IBag and approved based on member having benefit available