5-15-12 CLAIMS pg.342

Question 1

Invalid birthdate

Answer 1

The birthdate submitted by the pharmacy sometimes does not match the birthdate in the insurer’s computer. To solve this problem, first double check that you have the correct birthdate for the patient.

Question 2

Prescriber is not a network provider

Answer 2

This type of reject is common to the Medicaid programs and is sometimes seen with HMO programs. Simply stated, only prescriptions issued by network prescribers are covered by the insurer.

Question 3

Patient not covered (coverage terminated)

Answer 3

This can occur when a patient has a new insurance card, whether the new card is issued by the same insurer or a new one. If the insurer has not changed, perhaps billing numbers have changed (new cardholder identification number, group number, etc.)

Question 4

Refill too soon

Answer 4

Most third party plans require that most of the medication has been taken before the plan will cover another dispensing of the same medication. Early refills should always be brought to the attention of the pharmacist. If the pharmacist thinks it is appropriate to dispense a refill early (for example, if a patient is going on vacation) the next step is to contact the insurer to determine if it will pay for an early refill.

Question 5

Refills not covered

Answer 5

Many managed care health programs require mail order pharmacies to fill prescriptions for maintenance medications. Patients often are not aware of the mail order requirements of their prescription drug coverage. Ideally the employer is responsible to explain the mail order requirements if their employees are required to use mail order for maintenance medications. Sometimes, patients do not realize this restriction until prescription claims are rejected at their community pharmacy. In such cases, the pharmacy technician will have to contact the insurer to determine if emergency refills are covered at the community pharmacy.