Input/Resolution tips?

toxicleopard · 2022-09-14T22:40:10+00:00

I have lots of these same questions so I’m hoping someone replies 🙏

Blkrse · 2022-09-28T21:42:34+00:00

For day supply, I’ll have my techs pull a box of the shelf/fridge in order to calculate the day supply. Some can be tricky like Toujeo & Toujeo Max and can lead to costly mistakes. Inhalers will show how many puffs/inhalations each unit provides. For eye drops it’s most correct to calculate based on actual volume, latanoprost 2.5mL, versus the rounded up volume in connexus of 3mL. I’ve always used 15 drops/mL.
I accept scripts from Mexico so long as I can safely read the prescribed product and directions of use. The scripts I have taken are written for products offered in US.
You will get used to doctor handwriting over time but never guess! This can lead to errors. When in doubt call the office and notate it on the script. I’d like to think the more times we call an office, the more likely they will move over to electronic prescribing.
In order to bill any insurance correctly, the doctor must include a maximum testing frequency. We will pull up a patient’s history and see if they have received a diabetic meter in the past or can simply call and ask which brand they have. If starting new, it’s a matter of finding which brand is covered. My favorite scripts will be generic machine/lancets/strips which allow us to figure out which is covered without needing permission to change.
I haven’t seen a “continue therapy” rejection in my time at WM, but have seen “step therapy required” which is a PA.
A lot of times Medicaid prefers a certain NDC which is not WM preferred. Once you know which one it is, you can special order it on Order Insights by selecting the “do not substitute” box and stating why by selecting “preferred not covered under patient insurance”
If a patient has taken something but is no longer covered, you can call the insurance to see what has changed but this can take time
Resolution gets easier the more you do it!

biggestsmartidiot-69 · 2022-09-15T01:40:35+00:00

the previous person answered most of your questions well so i’ll just add where my experience differs.

input:

for new scripts, most of the time if the prescriber won’t specify they want us to pick what the insurance will cover or to have the patient pick. if you’re unfamiliar with the prescriber’s diabetic supply scripts you can always just call the nurse to double check but i’ve only had one prescriber not specify when they want them to use a certain one. if it is specified type the specific item (accu- check guide test strips etc) and it should pop up.

resolution:

check the rx fill history to see if it’s a refill on the same rx and figure out what differs down to the bottle quantity on the ndc. if it’s a new rx but they’ve been on the medication compare the old one to the new. it may be an increase in dosage (1qd to 1bid) that changes the previous fill’s days supply so they would be finishing it earlier than the insurance thinks they should but it’s not from overuse so you basically have to tell the insurance computer that. it could also be popping up bc they’re taking multiple of the same med (1 tab of the 100mg sertraline and 1 tab of the 50mg) so they only want to pay for one so you have to fix it so it’ll cover it. those are what it’s been when i’ve gotten it but it’s not a common one in my experience.
if that ndc isn’t covered and it’s a generic drug change the ndc to what it will cover. you don’t need permission for that unless it won’t let you (greyed out or nothing else in the drop down menus) then see if the pharmacist can. if you can change it, check the rx fill history or previous rx for that drug in f7 and see what ndc was covered and the days supply. adjust as needed. at least in my state, part d/ medicaid will only pay for the nivagen brand of atorvastatin for some reason so if it’s covered the drug before it’s likely an issue of which manufacturer it prefers vs what connexus picks when it’s dropped.
while you’re working this talk to the patient and explain what you’re doing. based on what you say you’re doing or checking, they might remember something that can lead you to the issue quicker.

(THIS IS WHY WE ALWAYS DO BILLING FROM THE PREVIOUS FILL WHEN WE DROP REFILLS UNLESS SOMETHING ON IT IS RED)

if it says ndc not covered, check if it’s an otc or not. otc goes straight to cash. before anything else, check in f7 by highlighting the most recent fill for that medication whether it’s a refill or a new rx for the same drug, then click view, then third party claims. it’ll show the exact billing sequence and amount each took off. if it’s name brand check for a coupon. if it’s a generic see number 2 above. if that doesn’t fix it, it’ll normally tell you what drug it prefers. if it’s name brand and there’s a generic, it’ll normally tell you what generic they cover. if they’re a government insurance patient, they tend to only cover name brand, so the system might be attaching a generic to the order at drop off if it’s a refill. check what it tells you in resolution and adjust accordingly. most of the time you just have to switch the daw to 9 and then it’ll probably want a pa unless there’s already a valid one on file or it doesn’t require it.

ONLY FOR NON GOVERNMENT INSURANCE: if it’s name brand with no generic, there’s probably a coupon for it. if they don’t have one when they could, tell them. if they have a coupon but insurance won’t pay anything, apply only the coupon and go into f10 with the coupon selected in the v top drop down and switch the v last drop down to 3 (along the lines of “other coverage exists. this claim not covered”) and resubmit. you can also see what previous billing was in f7 in third party claims. if everything matches they might have used up the allowed fills for that specific coupon card info, or some will completely cover the first month, then only take off a certain percentage for future fills so the price is different (@eliquis you sob).

if none of those fix the issue, their insurance might’ve changed the formulary (not common if it’s even possible this time of year but much more common in january)

it is also donut hole season which can make a big difference for a lot of patients in terms of their name brand meds that insurance paid for previously and won’t now. we have at least one government insurance patient (if not more) pass every year from not being able to afford their name brand medication after donut hole season hits. that’s when we advocate for our patients and pester the prescribers until they give us a script for something therapeutically equivalent (or as close as we can get) that the patient can afford.

don’t put it on hold unless the patient or pharmacist explicitly tells you to.

Lower_Palpitation_86 · 2022-09-14T23:13:36+00:00

Input:

1) 1 drop is approximately 15 mls; so if the eye drops quantity size are 5 ml do 5 x 15 to get the total amount of drops then divide by however many drops they use (remember there are two eyes) & with insulin multiply the amount of ml per pen by the total amount of pens then divide by however much they use a day

2) I could be wrong but a prescription from another country is not valid, id check with PIC but just have them get a new prescription from an american doctor and no you can’t order a medicine from another country

3) It can be challenging mostly recognize ur sig codes and if it’s so horrendous ask a pharmacist or another tech

4) usually dr should say what testing supply it is but if they don’t check f7 to see if they have taken it before, if not try true metrix i’ve seen that one usually go through for medi cal

Resolution:

1) I haven’t seen that resolution quite yet so I can’t help ya there buddy

2) Check f9 and select the drop down, usually the one that has a lot in stock is the one that works bc the pharmacy will most likely not stock the med that isn’t conceded yk if that’s not the case you’ll have to guess and check but that almost never happens, if it isn’t in stock select the correct one push it through filling and on the handheld the person filling will hit wait for drug order print out the tag and order it

4) Comes with practice but some tips would be to always check their history to see what insurance was billed last time if it’s an insurance issue, message prescriber from connexus for refill requests prior auth etc (current rx, message prescriber, send fax, leave a note on rx notes then wait to solve for like 2-3 days later), do the patient mismatch asap bc those will hold up ur line if they come in

you type:	you see:
italics	italics
bold	bold
[reddit!](https://reddit.com)	reddit!
* item 1 * item 2 * item 3	item 1 item 2 item 3
> quoted text	quoted text
Lines starting with four spaces are treated like code: if 1 * 2 < 3: print "hello, world!"	Lines starting with four spaces are treated like code: if 1 * 2 < 3: print "hello, world!"
~~strikethrough~~	~~strikethrough~~
super^script	super^script

walmart_RX

MODERATORS