Question on Part D billing pain meds

[Baalzeebub]

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There is a patient getting rxs for 1 LA and 1 SA opiate monthly. We are not sure if his doctor has done a PA. The LA always goes through but the SA sometimes rejects, sometimes goes through. Recently both went through, but the SA was reversed for a mfg change, then rejected when reprocessed. Called the insurance, they say reject is for exceeding morphine equivalent and needs PA. Says they have no record of the initial claim even though I have a leaflet with a claim # and a copay amount. Any advice on dealing with these?

 

[Digsbe]

Were the day supplies changed? If you get a paid claim at one point they should be able to see that in their system too.

 

[Lnsean]

There is a patient getting rxs for 1 LA and 1 SA opiate monthly. We are not sure if his doctor has done a PA. The LA always goes through but the SA sometimes rejects, sometimes goes through. Recently both went through, but the SA was reversed for a mfg change, then rejected when reprocessed. Called the insurance, they say reject is for exceeding morphine equivalent and needs PA. Says they have no record of the initial claim even though I have a leaflet with a claim # and a copay amount. Any advice on dealing with these?

Is it a soft reject? You can override these with DUR codes M0, G0, and 1B. I have gotten these soft rejects that say it's PA--for the same reason you are getting (exceeding morph equiv limit)--- when in actuality they are not. I cannot remember the plan names----hinting at AARP and maybe HUMANA.

 

[Baalzeebub]

Is it a soft reject? You can override these with DUR codes M0, G0, and 1B. I have gotten these soft rejects that say it's PA--for the same reason you are getting (exceeding morph equiv limit)--- when in actuality they are not. I cannot remember the plan names----hinting at AARP and maybe HUMANA.

no DUR codes worked. Nothing changed except NDC. When I called , the rep said it was over the monthly limit and needed PA from the doctor. I explained it had adjudicated just 5 minutes ago, she said she had no record of that at all. One of the strangest things I've ever seen in pharmacy. The only thing I can possibly think of is something about the order which they were entered in.

 

[BidingMyTime]

The only thing I can possibly think of is something about the order which they were entered in.

As odd as that sounds, that is a possibility. I saw an insurance once that would only pay for syringes if the insulin was processed first, if the syringes were ran first it would reject for PA. Of course this would make more logical sense than reversing the order of 2 opiates.....but insurances are strange. Expect the unexpected with insurances, and they you won't be disappointed.

 

[owlegrad]

I bet the first order didn't properly reverse so that when you changed the NDC it thought that the ME's were too high. Don't know how you can fix it if that's the case though.

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[Baalzeebub]

I bet the first order didn't properly reverse so that when you changed the NDC it thought that the ME's were too high. Don't know how you can fix it if that's the case though.

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That's what I was thinking

As odd as that sounds, that is a possibility. I saw an insurance once that would only pay for syringes if the insulin was processed first, if the syringes were ran first it would reject for PA. Of course this would make more logical sense than reversing the order of 2 opiates.....but insurances are strange. Expect the unexpected with insurances, and they you won't be disappointed.

I was thinking that maybe the PA was done, but I'm not sure if it is a general override of the morphine limits, or specific to 1 drug. If, for example, the PA override is only for the LA, then entering LA first wouldn't kick in the overidde, so entering the SA next would exceed limits. I should have asked the insurance rep if a PA was in the system. Anyways, will update next time they come in. Hopefully I can figure it out so that it may help someone in the future with a similar problem.

 

[RxPreceptor]

Word to the wise, before editing a script with a questionable past Hx of billing problems, check out the additional TP info section & write down the PA# if there is one before changing the Rx.

 

[Lnsean]

Word to the wise, before editing a script with a questionable past Hx of billing problems, check out the additional TP info section & write down the PA# if there is one before changing the Rx.

you must not work in a busy pharmacy...good luck with that