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