Adjudication Rejection Reference (Mod 4 Doc)

Question 1

Refill Too Soon

Answer 1

Inform patient of issues, offer to fill it out of pocket, or wait until the current day supply expires

Pharmacies are not to fill controlled medication (CII- CV) more than 3 days before they’re due

Question 2

Missing Origin Code

Answer 2

All Medicare-D claims require an origin code submitted with every claim

Question 3

Prior Authorization

Answer 3

The insurance company requires the doctor to declare that it is medically necessary that the patient receive this prescription

Inform the patient of issue, explain that these typically take a week or so to resolve

The patient has the option of paying for the medication out of pocket

Question 4

Invalid Cardholder ID

Answer 4

Need updated insurance info from the patient. Fill as cash then let patient know at pickup that we need additional information

Question 5

Missing/ Invalid Prescriber

Answer 5

The prescriber associated with the claim has incomplete information, typically NPI/DEA numbers. Enter the missing information under the prescriber’s profile and resubmit

Question 6

Medication Not Covered

Answer 6

Inform the patient their insurance doesn’t pay for this medication and that they can either pay out of pocket for it, or we can contact the doctor for a change in therapy

Occasionally the insurance company will indicate which medication they prefer for a specific condition. Follow the previous step for resolution

Question 7

Missing/ Invalid Diagnosis Code

Answer 7

All Medicare-B claims involving diabetic supplies require a diagnosis code with every claim
Type 1 Diabetes- those requiring insulin- 250.00
Type 2 Diabetes- those on an oral glucose replacement therapy-
250.01

Question 8

Therapeutic Duplication

Answer 8

A situation where the patient is taking multiple prescriptions for the same condition

Call insurance company for override, inform pharmacist of duplication of therapy