1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice
  3. Hey Texans—join us for a DFW meetup! Click here to learn more.
    Dismiss Notice

Insurance overrides

Discussion in 'Pharmacy' started by tompharm, Aug 19, 2015.

  1. tompharm

    7+ Year Member

    Joined:
    Aug 2, 2007
    Messages:
    173
    Likes Received:
    7
    Status:
    Pre-Pharmacy
    Is there anywhere or any book I can use as a reference for insurance overrides. I have been kind of shielded as far as insurance goes but now I need to put on my big boy pants and learn billing. So I was wondering if anybody can recommend anything.
     
  2. Note: SDN Members do not see this ad.

  3. trailerpark

    5+ Year Member

    Joined:
    May 27, 2013
    Messages:
    1,338
    Likes Received:
    679
    Status:
    Pharmacist
    Sorry, must do on the job training for insurance. Especially State insurance plans. Start with entering the BIN, PCN, ID, name and group number. Add a little cardholder or spouse and throw in a person code of 00 for cardholder or 01 for spouse and that's a good start.
    upload_2015-8-20_0-26-38.jpeg
     
  4. pillpharmer14

    pillpharmer14 pharmin' til' it's gone

    Joined:
    Mar 17, 2015
    Messages:
    207
    Likes Received:
    132
    Status:
    Pharmacist
    Then move onto the secret ID number lingo, such as remove three of the four leading letters and add the person code to the end and boom, all of the sudden it works.
     
    owlegrad likes this.
  5. tompharm

    7+ Year Member

    Joined:
    Aug 2, 2007
    Messages:
    173
    Likes Received:
    7
    Status:
    Pre-Pharmacy
    Could I theoretically call the insurance company every time I get a rejection until I learn how to stand on my own two feet?
     
  6. zelman

    7+ Year Member

    Joined:
    Nov 27, 2009
    Messages:
    3,174
    Likes Received:
    2,504
    Status:
    Pharmacist
    Absolutely. Just make sure you remember what made it work so you can do it without calling the next time.
     
  7. Wheresmyaricept

    2+ Year Member

    Joined:
    Jun 15, 2011
    Messages:
    321
    Likes Received:
    135
    Status:
    Pre-Pharmacy
    Theoretically, yes. Practically speaking, no.
     
  8. HelpfulPharmer1

    2+ Year Member

    Joined:
    Apr 20, 2014
    Messages:
    88
    Likes Received:
    36
    Status:
    Pharmacist

    Please try this book and let us know. They even have Electronic version and Renting option.
    Medical Insurance for Pharmacy Technicians 1st Edition
    by Janet Liles (Author), Cynthia Newby (Author)



    4 reviews so far and reviewers gave good rating...



    Rent

    $35.68

    Deliver to your Fire, iOS, Android, PC, or Mac with the free Kindle App

    Wow, technology :)
     
  9. tompharm

    7+ Year Member

    Joined:
    Aug 2, 2007
    Messages:
    173
    Likes Received:
    7
    Status:
    Pre-Pharmacy
    I bought the book, it should be here sometime this weekend. I will let you know if it is any good.
     
    HelpfulPharmer1 likes this.
  10. tompharm

    7+ Year Member

    Joined:
    Aug 2, 2007
    Messages:
    173
    Likes Received:
    7
    Status:
    Pre-Pharmacy
    I decided to download the electronic book and it doesn't really talk about rejections.
     
  11. tompharm

    7+ Year Member

    Joined:
    Aug 2, 2007
    Messages:
    173
    Likes Received:
    7
    Status:
    Pre-Pharmacy
    What are the most common one I should memorize and the ones I should prepare to call the insurance companies
     
  12. zelman

    7+ Year Member

    Joined:
    Nov 27, 2009
    Messages:
    3,174
    Likes Received:
    2,504
    Status:
    Pharmacist
    Every. Single. One.

    If you call an insurance company two separate times to find out how to fix the same reject, you have wasted your time.

    ...the rest.
     
  13. pezdispenser

    10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    1,491
    Likes Received:
    597
    Status:
    Pharmacist
    There were some other threads on this, so I'll copy and revise what I wrote there:

    http://forums.studentdoctor.net/threads/how-the-heck-do-you-learn-inurance-computer-systems.1028848/
    http://forums.studentdoctor.net/threads/common-insurance-rejections-and-insurance-cards.1048847/

    Techs can handle most insurance issues but there are some that the pharmacist is supposed to do.

    Disclaimer: inappropriate use of these codes could result in third-party chargebacks to your store.

    PPS Professional Pharmacy Services Codes
    Sometimes the insurance will identify a DUR issue like a drug-drug (DD) interaction or therapeutic duplication (TD) that the pharmacist will have to override. Copy each DUR code (DD, TD, etc) from the message to the input box in your software, then for each one enter an intervention such as "R0 Pharmacist reviewed" and the outcome such as "1B Filled as is".

    Some insurances only accept "M0 Prescriber consulted" and "1G Filled with prescriber approval" so you are meant to call or "call" the prescriber and document in case you get audited. Plans that need the M0/1G override include: Medco, Coventry, Florida Blue Cross

    EnvisionCare, Advantage Medicare Part D, Health Choice of Arizona Medicaid, require the MR (Medication Review)/1B code.

    Benecard PBF requires DE (Dosing evaluation)/1B.

    Catalyst requires a call to them to override every single DUR.

    Submission Clarification: 02 Other override
    Medco has a lot of these rejects where the message says for example, the dose is too high on a pediatric script, zolpidem 10mg qhs is too much for a geriatric patient, or verify the CrCl is okay or adjust the dose. Call or "call" the prescriber and document, then enter the 02 override code.

    Dosage change override
    If the rejection is for an early refill but you review the history and there was a dosage change, sometimes you can override it with one of the following Prior Authorization Type 1 codes depending on which insurance it is:
    00000000003
    45645645641
    22222222222
     
    #12 pezdispenser, Aug 22, 2015
    Last edited: Aug 22, 2015

Share This Page