Adjudication Rejects

these are some of the adjudication rejects/information I encountered and gathered while doing my externship, as well as some that I learned from class.

metformin (OSM)

OSM = extended release.

if reject code wants you to select the GENERIC (glucophage) but there’s none in the system or to order, you will select ‘metformin ER' version. should let you proceed as usual.

‘part D exclusion plan, plan exclusion’

at this point, Medicare will NOT cover for drug. you can run as discount and let patient know.

‘DUR-1 PPS CODE REQD’

aka ‘drug interaction (in this case, opioids and benzo)’ reject code.

basically telling you about a drug interaction with another drug that is active on their profile. if prescribed by SAME PROVIDER, you’re safe to bypass.

go to: ‘add info.’ on profile, DUR. you’ll type in: DD, M0, 1G.

*AFS* GLP-1 agonist not covered for diagnosis other than +2d w/o prior auth.

usually pops up for insulins that don’t seem to have a code for the insurance to bill.

go to patient’s profile > “health” > get code (usually at bottom, varies) > “additional info” > “diagnosis code” > reason 02 > type code in.

patient is in inbound, but their profile is not showing up

first try searching up ‘corporate’ with DOB, then with their name only, and both DOB & name if neither work.

if neither methods work, you will then create a NEW PATIENT PROFILE for them (allergies, street address, phone number, and insurance are important)

how to receive new orders on computer

tools > inventory > receiving > click, review, and verify each tab of the new orders > then hit ‘received.’

how to access credit/debit cards on file (applicable for GoldenSteps)

search > type in patient’s name > patient notes > card info should be available.

you will then enter card info. manually on pinpad.

‘bill claim to Medicare part B’ (test strips)

in this case, if some meds aren’t covered, you got to call the patient and let them know.

‘DD, M0, 1G’

code used for prescriptions with drug to drug interactions. only use if SAME DOCTOR has prescribed those medications.

‘max daily dose is 4 days’

try changing the day supply to 8 days…

flex cards vs health savings card (audits)

flex cards are able to be paused for whatever reason, but mainly due to the company processing the patients’ paperwork.

health savings cards are always opened.

‘member not active on date filled’

you can…

1. try changing the insurance by using the BIN #, then select the one without PCN #.

2. see if they’ve changed insurances by letting the system search.

3. if still NOT accepting, you will have to process as CASH. go to order notes & write ‘new ins.’

suspensions dispensed qty’s

if written quantity is different from dispensed quantity, make sure you reselect dispensed product appropriate to written qty

ex: 140 mL as written, select 2 75 mL’s, then change dispensed for 150 mL.

changing the next refill dates

auto resubmit > put in date that it will be filled by > select submit

creams & day supplies (for insurance purposes)

22 gm = 10 DS

30 gm = 10 DS *if only on body/legs/bigger amt used*, 7DS if small amt.

80 gm (or more) = 30 DS

IMITREX / sumatriptan DS

insurance won’t allow no more than 9 tablets for 27 days. change DS to 27 days if it rejects.

‘not covered for ages 18+ plan exclusion. 70, drug not covered, plan exclusion.

switch to discount scriptcycle, then add to notes that insurance will not cover.

patient refill requests that are not on their profile

1. make sure you look at their profile and get an Rx#.

   1. if that doesn’t work out, print out a FAX hardcopy of their transfers.

‘addictive toxicity: APAP INC RX <4000 mg’

try changing the DS from 1 to 2, etc. until it goes through.