Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Prior Authorization User Guide January 2017
SCOPE
This manual reviews the navigation and functionality of the Prior Authorization system specifically as it is utilized by CareFirst BlueCross BlueShield and/or CareFirst BlueChoice, Inc. (CareFirst) provider users.
Confidential and Proprietary Page 1 of 30
Not To Be Reproduced Or Disclosed to Others Without Prior Written Approval ELECTRONIC DATA = OFFICIAL VERSION – PAPER COPY – INFORMATIONAL ONLY
CVS Caremark is an independent company that provides pharmacy benefit management services to CareFirst members.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue
Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
PAUserGuide (3/17)
Confidential and P roprietary P age 2 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
1.LOGGING IN
1. Log in by entering your User ID and password and click Login.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 3 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
2. Click on the Prior Auth/Notifications tab.
3. Click on the Prior Authorizations tab.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 4 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
4. Click on the Add New tab and select Drug Prior Authorization from the dropdown
5. Enter the member information. The membership ID is a required field. Then click
Search.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 5 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
6. The system will show that member’s policy. Select the radio button, as shown
above, for the member that requires the authorization then click Submit.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 6 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
7. If the member has medical coverage only, the system requires you to select the
drug to determine if it is a drug that requires prior authorization. Follow the prompts
on the screen.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 7 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
8. Select the correct provider form the dropdown list and click Submit.
*You will only see this screen if there is more than one NPI number under your Tax
ID.
*If you do not see the provider in the dropdown, contact the CareFirst Help Desk at
877-526-8390.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 8 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
You will then be brought to the CVS Caremark homepage.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 9 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
2. CREATE AN AUTHORIZATION REQUESTAll authorizations that have been submitted will be available through the Find Authorization option.
1. From the User Home Page, hover over Authorizations and click Create
Authorization
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 10 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
Step 1 – Getting Started
1. To select your patient either enter the Member ID under Quick Start to search for
existing authorizations to copy
OR
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 11 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
1. Enter the Member ID and Date of Birth under the Search for Existing Patient field
click Search
2. Click on line to select your member from the results returned at the bottom of the
screen.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 12 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
Step 2 – Enter Patient Detail
1. Confirm Patient information and complete any additional fields under the Patient
Detail screen
2. Click Next
Click on drop-down box next to each heading to expand/collapse each section.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 13 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
Step 3 – Enter Authorization Detail
1. Complete fields for Billing Physician and any other required or applicable authorization
detail fields
2. Click Next
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 14 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
Step 4 – Enter authorization Lines
1. Enter applicable start and end dates under Date(s) of Service
2. Enter requested drug name or NDC into NDC Code
3. Click Next
4. Review information entered under the Authorization Detail Screen.
5. If no changes are needed, select Submit
*If you would like to print your request, you may do so by expanding all collapsed fields on the screen and printing prior to clicking the Submit button.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 15 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
Step 5 – Completing the Protocols / Questionset
Upon clicking Submit, if your request falls under the medical benefit, you will be brought
through a series of protocol questions that will display on the screen.
1. Answer clinical questions as they are presented in the pop up screen that
displays, and click Next to move on to the next question.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 16 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
2. Once the protocol questions are completed, your authorization will be auto
approved, or released to the next party for review. Once the outcome is
displayed on the last pop up, click DONE.
The outcome or status of the authorization will be displayed at the top of the screen along
with the authorization number assigned.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 17 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
*See individual line detail for the status of the line
If your request falls under the Pharmacy benefit, upon clicking Submit, your request will be
sent to the CVS Caremark system and the authorization request status will display as Pending Questionset.
*There will be a delay in obtaining the Questionset from the CVS Caremark system, as the
information passes between two systems.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 18 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
The Authorization will be viewable form your homepage under the Pending Questionset
queue.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 19 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
The CVS Caremark system will send back your authorization request with the applicable
clinical questions for your completion, if the requested drug requires prior authorization.
The Authorization request will appear on your home page in the Workbox under the
Questionset Received queue.
*Please note – The Questionset will expire in three days if not completed. If that occurs, you will need to locate the authorization by using the Find Authorization feature and create a copy of that Authorization.
1. To complete the clinical Questionset, click on the Questionset Received queue
to display the list of authorizations in that category.
2. Select your authorization request by clicking on the task description for that
authorization in blue.
You will then be brought to the detail of the authorization request.
To complete the clinical questions, click Submit
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 20 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
3. Answer clinical questions as they are presented in the pop up screen that
displays, and click Next to move on to the next question.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 21 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
4. Once clinical questions have been completed, click Done.
The clinical questions screen will then close and the authorization request
will be sent back to the CVS Caremark system for a determination and the
Authorization will be placed in a Pending Decision status.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 22 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
The Authorization will be viewable form your homepage under the Pending Decision
queue.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 23 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
3. Once a determination is made, the Authorization will be sent back to your
homepage under the Provider Notification queue. You will then be able to
open the authorization to review the determination of your Authorization
request, and accept the notification.
*Please note – You will not receive a notification from the system once a
determination has been made. You will need to check your provider
homepage under the Provider Notification queue to view the outcome of
your Authorization request.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 24 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
1. To accept the notification, from the detail screen of the authorization, click Accept
Notification at the bottom of the screen.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 25 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
3. NOTES
After creation you will have access to add additional Notes. Please be advised that
notes for authorizations in this tool, that fall under the pharmacy benefit, are not
sent to the CVS Caremark system and are viewable only by the Provider.
1. Click Add Note
2. Enter your desired note in the notes window that is presented and click Save.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 25 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
4. DOCUMENTS
Additional documentation can be added to any authorization at any time. Please be
advised that documents attached to authorizations, that fall under the pharmacy benefit
are not sent to the CVS Caremark system, and are viewable only by the Provider.
1. Select Add Document
If prompted to add a document during the clinical question process, you can save and
close your clinical questions and add the document or you can add after the questions have
been completed.
2. Browse through your directories to locate the desired file
3. Select Document
4. Rename the document
5. Click Upload to attach
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 27 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
5. FIND AN AUTHORIZATION
1. From the Homepage select the Authorization tab on the top navigation menu then
select Find Authorization.
1. Enter Search Criteria
2. Click Search
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 28 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
3. Select the Authorization to be reviewed from search results
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 29 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
6. FILTERSWhen selecting authorizations to work, from a specific shared queue in your workbox on
your homepage, you have the ability to apply filters to view only the authorizations you
want to see.
1. Expand the queue you wish to view and apply your filter to by clicking on the
queue name.
2. On the right-hand side of the workbox, click Show Filters.
3. Enter the wanted data in the corresponding filter field and click the filter icon
next to the field to apply your parameters.
4. Click Filter to apply your request.
Prior Authorization User Guide – January 2017
Confidential and P roprietary P age 30 of 30Not To Be Reproduced O r Disc losed to O thers Without P rior Written A pproval
ELEC TRO NIC DA TA = O FFIC IA L V ERSIO N – PA PER C O PY – INFO RMA TIO NA L O NLY
Your results will be presented in the resulting workbox.
Prior Authorization User Guide – January 2017