Notes

OTC Expense,

Mentor:
Balance Due; Humana Pharmacy and Humana Specialty Pharmacy Directory
OTC; Price Quotes
OMS Basic Navigation Member Search
Wismo

Documenting call:
-Classification: OTC, Intent: Billing


> OTC Price Quote
-HPCC Working OTC Calls

> Documenting Call
-C: OTC, I: Pharmacy Concern - General Information

>OTC WISMO
Queue / Then ... ( MENTOR DOCS )
Credit Card Exceptions -Call center working orders in credit card exceptions queue
On Hold - ON HOLD
Failed claims - OTC failed claims
HIPAA verification queue - HIPAA Verification Queue
Inventory Allocation - Inventory allocation, se the Inventory sharepoint site
Shipped - OTC Shipped
Fulfillment - Dispensing queue

If not on file; Placing Phone Orders
1.Mail - if the order was mailed 14 days or less days ago, advise the member that the order has not been received and has not exceed delivery TAT.
2.Fax- order form was faxed les than 72hrs, advise the member that the fax has not been processed and not exceed delivery TAT,
3.Web - Determine if the member received a confirmation # when the order was placed.

if the is CANCELLED; Placing Phone Orders
Credit card not file - Recreate the order w/ a credit card.

Month not specified - Recreate the order

Account shows a credit balance and no order is on file - cancelled on current month, Recreate the order manually by sending an email RS1OTC asking to place the order and apply the credit balance.
if previous month, Recreate the order manually by sending a email to OTC-ESC using the template provided by your leader, asking the place order and apply the credit balance.



HPCC DIG Toolbar
>Process
Copy notes, Escalation Request, Request Plan Doc, OTC Order process, Prior auth form


Escalation Request;
Day Supply - member's current supply of the medication
Order Numbers - All orders currently on the members profile, select the order(s) in question.
Provider Name, Phone, and Fax # - if the fax is not available type NA
Prescription (Name & Strength) - Add both prescription name and strength
Account Issue - Policy update request requires this field to be populated to submit



HPCC Enrolling New Members

-Qualifying members;

>Calls Requesting Enrollment
1. Ask general informations / LISTEN carefully
2. Ask for specific information / Show EMPATHY
3. Ask Directly / REFRAME the request, & ASK PERMISSION

Qualifying the member;
Before starting the process of enrolling a new member you must take steps to qualify the member and understand the members specific request.

1. Authenticate and verify the member
2. Determine if the member already has a Humana Pharmacy account
3. Establish the names and strengths of the prescription
4. Ascertain if the member needs diabetic supplies
5. review the members plan type
6. Find out if the member has prescription in hand that are written for a 90-day supply

Enrolling New Members
Web registry creates a members profile so that it can be seen in CRM this is the starting point for all new accounts.

1.Cofirm that a new member has active coverage
2. Access Web Registry
3. Register a new member
5. Enter credit card information

Submitting Prescriptions
Prescriptions may be submitted in a variety of wats. You may be asked for general information or for specific information.

1. Mailing prescription to Humana Pharmacy
2. Submitting prescription for controlled substances
3. Switching prescriptions on www.humanapharmacy.com
4. Submitting prescription by phone
5. Faxing prescription to Humana
6. The ePrescribe option for providers

Educating New Members
It is important to let new members know how to take advantage of the great benefits Humana Pharmacy Offers.

1. Self-service options
2. New prescription and refill turn around times (TAT)
3. Billing and payment information


AUTHENTICATE AND VERIFY THE MEMBER
1. Members or Parent/Guardian of a minor in which the relationship is able to be verified on share plan
-What should be obtained?
Patient Name +3 Member Identifiers

-Acceptable Identifiers
1.Memeber Identification Number
2.Social Security Number *Cannot ask for SSN but it is acceptable to use if its given during the call*
3.Medicare Identification Number
4.Members Address (Street or house number)
5.Member Date of Birth
6.Member ZIP code
7.Member group name, group number (suffix not required) or product type


2.Caller on behalf of a member with consent or power of attorney on file
-What should be obtained?
Name of member +3 identifiers and verify if consent or power of attorney is on file

Member Identifiers
1.Members Identification Number
2. Social Security Number *Cannot ask for SSN, but it is acceptable to use if its given during the call*
3.Medicare Identification Number
4.Address (st or house number)
5.DOB
6.ZIP Code
7.Members group name, group number (suffix not required) or product type


3.Caller on behalf of member without consent or power of attorney on file
*This includes parent/guardian of minor who is not listed on the same plan as the minor to verify relationship*
-What should be obtained?
1. Obtain name of member +3 identifier
2.Authenticate the authority of the caller by verifying 2 of the following (implied consent) or by obtaining verbal consent from the member;
-Name of medication
-Order Number
-Strength of medication
-Date of Fill
-Rx Number
-Prescribing provider

Note; Once step 1 and step 2 are authenticated then Implied consent allows the release of the same information as Verbal Consent.

Important; If associate cannot authenticate the authority of the caller, personal health information may not be released.

Members Identifiers;
1.Members identification number
2. SSN - cannot ask for but acceptable to use if given during the call
2.Medicare identification number
4.Members address (St or house number)
5.DOB
6.ZIP code
7.Members group name, group number (suffix no required) or product type

>> MENTOR; HPCC DIABETIC SUPPLIES GENERAL INFORMATION

RxEducation (RxE)
- RxE team assits with the enrollment of the new member y handling all request for diabetic supplies.
-When members do not have prescriptions un-hand the team will reach out to prescribing physicians to obatin a full set of prescriptions that are written for a 90-day supply of medications.

Clinical Services
-The C2 Drug List contains drug that have a high potential for abuse and are subjected to severe restrictions. Abuse of these drugs may lead to extreme psychological or physical dependence.
-Because of this all prescriptions for medications on the C2 List must be handled by the Clinical Service Team.

+Warm transfer to clinical services.



ASK ABOUT DIABETIC SUPPLIES, PLAN TYPE, AND PRESCRIPTIONS;
1. what are the name and strengths of the prescriptions being requested?
2.Does the member need diabetic supplies?
3.Is the members plan type PDP only>
4. does the member have all prescriptions in hand?
5.are the prescription written for a 90-day supply?



PROCESS EX;
A. Wants to enroll for maintenance medications and does not have a Humana Pharmacy profile account set up and does not need diabetic supplies.

1.Determine if the member has a humana pharmacy profile account by referring to the pharmacy tab in CRM
- if no?
1.1. Create a profile account for the member access RXConnect Pro, the member will auto-populate and select the RTM link.

2.Ask for the names and strengths of the new Rx to ensure there will be no delays in processing.

3.Are the Rx listed on the call center c2 drug list?
-if no?
3.1. Ask if the member wishes to receive diabetic supplies?
3.2. Ask if the member has all her Rx in-hand?
-if yes?
3.3.Are the Rx written for a 90-day supply?
3.4.Ask if the member wants to mail in her Rx or have humana pharmacy contact her prescribing physician for our own set.

4.Member will mail in her Rx to Humana Pharmacy learn about Submitting Prescriptions.


B. Member is new who wants to enroll for diabetic supplies. However, he has a PDP only plan with Humana.
1.Ask if the member wishes to receive diabetic supplies?
-if yes?
1.1Review members plan type

2.If member plan type PDP only?
-if yes?
2.1 - Let member know that diabetic supplies are not available for PDP only plan type.
- the member can still receive regular maintenance medication from Humana Pharmacy
- Suggest that the member contact Medicare (800-633-4227 or www.medicare.gov ) to locate a diabetic supply provider.
-Ask if the member wishes to continue with the enrollment process for maintenance medications.


C. Member want to enroll for diabetic supplies and the maintenance medication for her blood pressure. the member does not have prescription in-hand.
1.Ask if the member wishes to receive diabetic supplies?
if yes?
1.1Review members plan type

2. is the plan type PDP only?
-if no?
2.1. tell the member you will assist with enrollment for her regular maintenance medications and her diabetic supplies

3.Ask if the member has all her prescriptions in-hand?
-if no?
3.1. Access RTM to start the prescription through RxConnect PRo.

4.Close the contact, Select the appropriate classification and intent in CRM



D. Member want to enroll for his maintenance medications and does nit need diabetic supplies and does not have his prescriptions in-hand.

1. Ask if the member wishes to receive diabetic supplies
-if no?
1.1 ask if the member has all his prescription in-hand?
-if no?
1.2Access RTM to start the prescription enrollment process through RxConnect Pro.

2. Close the contact, Select the appropriate classification and intent in CRM