tompharm

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Aug 2, 2007
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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.
 

trailerpark

7+ Year Member
May 27, 2013
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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
 

pillpharmer14

pharmin' til' it's gone
Mar 17, 2015
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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.
 
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tompharm

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7+ Year Member
Aug 2, 2007
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Could I theoretically call the insurance company every time I get a rejection until I learn how to stand on my own two feet?
 

zelman

10+ Year Member
Nov 27, 2009
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Could I theoretically call the insurance company every time I get a rejection until I learn how to stand on my own two feet?
Absolutely. Just make sure you remember what made it work so you can do it without calling the next time.
 

HelpfulPharmer1

2+ Year Member
Apr 20, 2014
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Pharmacist
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.

Please try this book and let us know. They even have Electronic version and Renting option.
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$35.68

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Wow, technology :)
 

tompharm

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I bought the book, it should be here sometime this weekend. I will let you know if it is any good.
 
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tompharm

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I bought the book, it should be here sometime this weekend. I will let you know if it is any good.
I decided to download the electronic book and it doesn't really talk about rejections.
 

tompharm

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Aug 2, 2007
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What are the most common one I should memorize and the ones I should prepare to call the insurance companies
 

pezdispenser

10+ Year Member
Dec 14, 2006
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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
 
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