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Part D vs. Part B
Complaint Call Types
Formulary and Utilization
MadGab
100
The below list of drugs and supplies are covered under what part of Medicare? Alcohol Swaps Gauze Injection Devices Insulin Pens Insulin (unless used in a pump) Syringes
What is Medicare Part D Reference: Prescription Coverage Part B or Part D
100
Read the definition below and determine the complaint type: When a member needs a refill too soon also known as OVERRIDE CCP’s must contact Optum Rx ***NOTE***: Members may have a refill too soon due to stolen medication, natural disaster, or maybe the member is traveling and needs medication for the travel period.
What is Administrative Coverage Determination
100
All formulary changes are not messaged in the outreach campaign that goes out in...
What is November to December. Reference: Formulary and Utilization Management
100
Of Lions Quarrel
What is A flying Squarrel
200
Read the definition below and determine the complaint type: When a member needs a refill too soon also known as OVERRIDE CCP’s must contact Optum Rx ***NOTE***: Members may have a refill too soon due to stolen medication, natural disaster, or maybe the member is traveling and needs medication for the travel period
What is Administrative Coverage Determination
200
This complaint type is a request for an independent appeal of the plan's decision to terminate Skilled Nursing Facility (SNF), Home Health Agency (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF) services. The member must submit a timely request to the QIO (generally, no later than noon of the day following the receipt of the “Notice of Medicare Non-Coverage” (NOMNC), or by noon the day before the coverage ends).
What is Fast Track Appeal. Reference: Complaints, Appeals, and Grievances Glossary
200
This administration occasionally removes a drug from the market for safety reasons. This drug then must be removed from all Part D formularies.
What is Food and Drug Administration Reference: Formulary and Utilization Management
200
Abe Who Beat Wrap
What is A boobytrap
300
This department will determine whether the drugs provided with the home infusion require an authorization for Part D coverage.
What is OptumRx Reference: Part B and D Covered Drugs Overview
300
Once OptumRx receives the information back from the member's provider, a decision will be made within ____ for standard coverage determination
What is 72 hours.
300
In 2014, UnitedHealthcare will incorporate some changes to their prescription drug formularies for which plans...
What is PDP and MAPD Plans.
300
Dawned Pea Hugger Limb Ann
What is Don't be a girly man!
400
If the physician will be administering the injectable or intravenous drug in the physician’s office as a part of the professional service, the drug is typically covered under Part B. The agent should check prior authorization requirements for the service in...
What is Notification Gateway Tool. Reference: Part B and D Coverage Overview.
400
Calls that are a routine question about a Non-Part D or Medicare Excluded Drug, where they do not argue/complain that the drug is not covered or feel that they are entitled to the excluded drug, should be treated as an...
What is General Inquiry
400
At times it is necessary to immediately remove a medication from the formulary without this notification
What is 60 Day
400
Fin Skate
What is Fense gate
500
This part od medicare generally doesn’t pay for self-administered drugs unless they are required for the hospital outpatient services you’re getting.
What is Part B. Reference: Part B vs. Part D Coverage Determination
500
This complaint type should be filed if it is beyond 60 days of the adverse coverage determination, a standard appeal can still occur if the member can show good cause that something prohibited them from being able to request an appeal in the allotted timeframe.
What is Good Cause Appeal. Reference Complaints, Appeals, and Grievances Intent
500
As of this date, current users of a medication classified as an HRM will experience non-formulary restrictions, prior authorization requirements, or new quantity limits.
What is 1/1/2014
500
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What is He's a Sly Fox