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Official Course
Description: MCCCD Approval:
4-27-04 |
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CSR139
2004 Spring – 2009 Summer I |
L+L |
3.0 Credit(s) |
4.0 Period(s) |
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Pharmacy
Benefit Operations |
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Pharmacy
benefit management company member service operations. Emphasis on claim
analysis and research, plan exception processing, and customer service
strategies. Covers call referral stipulations, file documentation, and call
center phone system usage. Prerequisites: None. |
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Go to Competencies Go to Outline
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MCCCD
Official Course Competencies: |
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CSR139 2004
Spring – 2009 Summer I |
Pharmacy Benefit Operations |
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1.
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Explain procedures for referring member questions that
must be answered by a pharmacist. (I) |
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2.
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Document account activity in a manner that allows for
multiple representatives to work the same account. (II) |
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3.
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Use customer service strategies in the provision of
telephone customer service. (III) |
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4.
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Demonstrate the ability to use an inbound call center
phone system. (IV) |
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5.
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Identify member questions that must be referred to persons
with specialized training. (V) |
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6.
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Cite key pharmacy benefit claim concepts. (VI) |
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7.
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Relate paid claim information to pharmacy benefit plan
members. (VII) |
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8.
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Explain rejected claim information to pharmacy benefit
plan members. (VIII) |
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9.
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Manage direct claims for reimbursement made by plan
members. (IX) |
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10.
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Perform plan benefit exclusion override procedures. (X) |
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11.
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Explain the concept of step therapy to inquiring plan
members. (XI) |
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12.
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Describe key pharmacy coverage plan exception concepts.
(XII) |
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13.
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Use communication strategies in dealing with internal
customers. (XIII) |
Go to Description Go to top of
Competencies
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MCCCD
Official Course Outline: |
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CSR139 2004
Spring – 2009 Summer I |
Pharmacy Benefit Operations |
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I. Pharmacist Question
Referral A. Referral Eligible
Questions B. Referral Procedures C. Documentation II. Account Activity
Documentation A. Follow-Up Notations B. Caller Contact
Information Capture III. Customer Service
Concerns A. Script Usage 1. Greeting 2. Closing B. Hold Issues 1. Transfer Holds 2. Research Holds C. Call Control IV. Phone System Usage A. Interactive Voice
Response (IRV) System B. Sign-On/Sign-Off C. Warm Transfer Procedures
D. Wait Time Status
Interpretation V. Question Referral
Concerns A. Pharmacy Technician
Questions B. Pharmacist Questions C. Urgency Identification D. Follow-Up Documentation
Issues VI. Claim Overview A. Prescription Number
Issues B. Status 1. Submitted 2. Paid C. Co-Pay Information D. Reject Code
Identification VII. Paid Claim Information
A. Paid Claim
Identification B. Financial Claim
Information C. Drug Information D. Claim Appeal Issues 1. Appeal Eligibility 2. Form Provision VIII. Rejected Claim
Information A. Information Access B. Rejection Code
Interpretation C. Claim Rejection Script
Usage IX. Direct Claim
Reimbursement A. Claim Processing
Concerns 1. Standard Claim
Processing 2. Foreign Claim Processing
3. Allergen Claim
Processing B. Plan Member Explanation C. Disbursement Concerns 1. Stop Reimbursement
Procedures 2. Check Reissue Procedures
X. Plan Benefit Override
Procedures A. Override Identification B. Overridable
Issues 1. Covered Drugs 2. Formulary 3. Maintenance C. Request Status Review XI. Step Therapy
Considerations A. Plan Stipulation
Explanation B. Drug Identification 1. History Drug 2. Claim Drug C. Step Therapy Claim
Research 1. Coverage Research 2. Rejected Claim Research XII. Benefit Plan Exception
Concepts A. Prior Authorization
Status B. Managed Access C. Managed Drug Limitations
XIII. Internal
Communication Concerns A. Feedback Provision B. Trust Establishment
Strategies |
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