RxClaims/Formulary Viewer Knowledge Check

After member search has been executed, before selecting the correct member, what information should be verified before proceeding to member profile?

What F-key is used to search or retrieve additional information, known as the “Hot Key” when applicable?

F12

When entering an Authorization, what ‘Reason code’ is the most common code and used for all routine authorizations?

When editing an authorization also known as maintaining an Authorization, what status (‘Sts’) code is used for most Part D Auths?

Lowercase m

Uppercase K

Uppercase M

Lowercase j

For Ondansetron, How far back do you wildcard the GPI?

GPI 10; Back 4 digits

GPI 12; Back 2 digits

GPI 8; Back 6 digits

GP I14; Not wildcarded to allow for specific dosage and form

What information needs to be populated in order to run a successful Mock Claim from Scratch?

Proc Ctrl, Facility ID, Claim Date, NDC#, Disp Qty, Day Supply

Proc Ctrl, Pharmacy ID, Claim Date, NDC#, Disp Qty, Day Supply

Proc Ctrl, Pharmacy ID, Claim Date, GPI#, Disp Qty, Day Supply

Proc Ctrl, Facility ID, Claim Date, GPI#, Disp Qty, Day Supply

For a Trillium Advantage member, on which account would we enter a Non-Formulary Authorization?

Primary

Secondary

Both

Maintaining an Authorization: Place 99999 in Daily Dose Max Column with an “S” in the Hot Keyed “Daily Dose Qual” Field, What Auth type requires this edit?

Age Restriction (Age Limit)

Financial QL

Max Dose (Safety Limit) QL

STCOB

Synthroid 125mcg tabs was approved until 12/31/18, DAW 1. Which Auth type would you follow according to Desktop 17?

Part D Auth 01

Part D Auth 02

Brand Name Medically Neccessary Auth 01

Brand Name Medically Neccessary Auth 02

From the Display Member Details screen, which F-key selection will provide the option to view ESRD information?

F10

F16

Once Mock Claim has been submitted, what F-key option is used to verify claim is paying against your Authorization?

F15

F17

F10

What does the icon ‘HNMC’ mean in formulary viewer?

HealthNet Medicaid Eligible

Medicare excluded, Medicaid Eligible

Medicaid excluded, Medicare Eligible

HealthNet Medicare Eligible

For HRM Age Limit review requests, which PA criteria will you use to review the case?

Drug Specific Criteria

Medicare Part D Tier Exception and Formulary Exception Requests Criteria

When selecting a Drug specific Criteria, in which region do you choose?

HNMC

NATL

MCPD

NVSS

Which Desktop is used to review RxClaims processing information?

Desktop 12

Desktop 10

Desktop 14

Desktop 17