Module 2 Flashcards
Information not provided code
0
Written prescription code
1
Telephone prescription code
2
Electronic prescriptions code
3
Facsimile prescription code
4
Transfer prescriptions/other
5
Member ID number
Specific to cardholder
PCN
processor control number
Secondary indentifier that may be used in routing pharmacy transactions. This number is defined by PBM as their number is unique to their business needs. Not all entities use PCN but most do
Rx BIN
Bank identification number
Bank of number, not money
Always a 6 digit number that health plans use to process electronic pharmacy claims, the number tells the pharmacy database which PBM will receive the claim for this prescription. In other words tells the pharmacy where to actually send the claim
Group number
Specific to a health group i.e UFHealth, smalls businesses can create one as well and it does help cut costs but not as much as larger groups
50
Non-matched pharmacy number
-occurs when a patient is trying to fill a prescription for a specialty medication at a non specialty pharmacy
- Contract the prescription plan company to find the nearest and/out contracted pharmacy
- Contract the patient abs explain issue
- Give the info to the patient so he/she can get the prescription filled OR
- Offer to transfer the prescription to the specialty pharmacy if there is only 1 option based on their plan
70
Plan exclusion
- medicationis not covered by the plan because the medication is denied “medically necessary” based on plan design and plan coverage
- obesity treatments
- medical foods
- fertility treatments
- any non formulary drug
- Contact patient and explain
- Inform patient of cost
- Ask the patient if they want you to fill the prescription or give prescription back to him/her
- Contract physician on behalf of the patient to switch the prescription to formulate drug
- there’s always a medical process (appeal) that the provider may submit but doesn’t mean they’ll get it
75
Prior authorization required
- prior auth is a utilization management program to ensure that the right patient receives the right medication at the right dose
- generally the medication is in the formulary however the insurance plan requires specific clinical criteria is met prior to the insurance company paying for the medication
- Contact the patient and explain
- The lamest sound call the payer/PBM to request a clinical form (may be online) for the provider to complete
- The pharmacy should send the provider the information to contract the plan and ask them to complete the form
- The providers office should complete the form and follow up until complete
- Lastly the pharmacy should follow up with provider to verify the PA was approved
76
Plan limitations exist
Multiple scenarios apply:
-minimum/maximum age
•all acne topical meds and/or ADHD meds will typically adjudicate without requiring PA if the patient is under 25
-quantity level limit
•maximum of 30 tablet per 30 days is the prescription is supposed to be dosed for one tablet daily per FDA labeled indication
- Contract the patient and explain
- Contract prescriber
- Ask the patient if they want you to fill the prescription or if they want it back
- Of the prescriber is requesting more than allowed dosing,a medical exception request may be completed to obtain coverage
78
Cost exceeds maximum
Fail save process designed for adjudication to catch any claim that exceeds a certain threshold
- Contact the patient
- Contact the plan to request an override
- Plans typically review that the indication is FDA approved and that the dissing is appropriate for the indication
- Contact the prescriber should the insurance company deny the request
79
Refill too soon
- occurs if the patient is trying to fill a prescription too early (they should have >1 week of medication left)
- plan only allows a 30 day silly of medication after 2-or more day silly has been consumed
- Contact the patient and explain the situation
- Inquire why the patient would like medication filled early
- vacation: can the plan and request an override
- lost medication: can the plan and request an override
- just because: explain to the patient that his/her plan will not allow the prescription to be filled until such fate
* note: not all plans will allow for an override for a refill too soon
88
DUR
Multiple scenarios apply
•gender alert
-claim rejects because the drug is not typically used for the gender prescribed
•drug-drug interaction
-seen when two medications processed for a single patient interact with eachother which would cause significant harm to the patient
•high dose alert
-seen when a medication is prescribed advice the maximal allowable
•high risk medication
-I’ve the age of 65 and pediatric patients
- Contact the patient
- Contract prescriber to verify the prescription information is correct
- Once verified contract the payer for override information OR
4 place override codes in the claims field to process the prescription
NCPDP
National council for prescription drug programs
Created a standardized list of rejection codes and assigned them a number
Allergy
- contact patient
- Clarify allergy information with the patient
- Determine “what happens when the medication is consumed”
- Has the patient successfully taken the medication before
- If they have but taken it, you may choose to call MD if needed to change the medication OR you can give them the medication and educate them on what to look for
- DOCUMENT-on the rx and in the computer notes
Clinical alerts and warnings
Allergy Drug drug interactions Duplicate theory Excessive dose High risk medications Pediatric dosing Beers criteria
Drug drug interactions
- contact the patient
- Research the interaction (if needed) to find the significance
- super easy to do
- dr. Office 9/10 will not know the interaction - Review the interaction with the patient
- Contract the physician to inform them of the interaction and to determine how the provider would like to move forward
- DOCUMENT- on rx and in the computer notes
Duplicate therapy
1 contact patient
- Consult with the patient to determine their understanding of taking the medication
- Discuss with the physician
- Have the patient contact the physician UF they are confused
- DOCUMENT-on the rx and in the computer notes
Excessive dose
- Call the provider to discuss the amount of medication prescribed to verify it is correct
- DOCUMENT-on the rx and in the computer notes
High risk medication
- Take a second look
- Verify the information on the rx is correct
- Increase or decrease in dose
- Contract the provider if you have any questions
- DOCUMENT on the rx and in the computer notes
Pediatric dosing
- double and triple verify the dose
- Update the child weight in the computer system
- Find out what the child was diagnosed with
- parents will know
- use simple terms - Any question AT ALL contract the prescriber
- DOCUMENT on the rx and in the computer notes
Beers criteria or list
- Contact patient
- A list of medications, using evidence based recommendations that are not appropriate to be given to elderly patients
- Review the list of recommended alternative medications
- Contact the provider to recommend alternate therapy
- DOCUMENT in rx and in the computer notes
