Calling an Insurance Company

For anyone who has ever worked in a pharmacy and had to deal with insurance claims and issues they know how frustrating it can be. Many times insurance doesn't do what you want it to do, and you end up not only frustrating the customer, but being angry with the fact that something has gone wrong along the line of processing.
Some of the general insurance issues that I run into on a regular basis include the following:

• Missing or Invalid Patient ID/Processor Control Number/Group ID
• Missing or Invalid Patient Age or Gender
• this is usually a flub by the insurance company because most times the patient is there letting you know their birthday and the gender of their children
• Missing or Invalid Patient Person Code 
• 01-Cardholder 02-Spouse 03-Child 
• Prior Authorization required
• Doctor and Insurance company must come to an agreement 
• Missing or Invalid Day Supply 
• this is often an easy fix, if the prescription was written for a 90 day supply and the patients insurance company-usually Medco, only lets the patient receive a 30 day supply at a time, you simply change the dispensed quantity to that within a 30 day range of time
• Sometimes if a patient has switched or increased their dosage and we have not yet received the prescription from the doctors office-we will need to call and let the insurance company know that there has been a change in dosage 
• If the patient does mail order and they haven't received their mail order drugs yet and need some to get by 
• Override Codes Needed
• Diagnosis Code
• this may be a company code or a specific insurance code
• generally when a code has been used the pharmacy intern, tech, or pharmacist will put a note in the patient profile so that the next person who tries to submit a claim for them doesn't have to go through the hassle of calling the insurance company 
• Vacation Override Code
• when people are going on vaccation and need an advance on their medications ahead of time
• Transplantation Codes
• liver, kidney, etc transplants need a certain code for insurance companies to pay for their medications which are often extremely pricey 
• Company Codes
• For Hy-Vee by putting a 999999 you can often override rejections that the system sees as inappropriate 
• these could include DT: duplicate therapy DD: drug dose or others as well 
• Vaccination Codes

There are many other codes that could qualify for these as well.

When one gets a rejection, they generally try to do all the different "Tricks" that they can think of to try and fix the problem without calling the insurance company, but this doesn't always hold true. Many times the insurance company needs to be called which can be a heinous task.

Here is how many phone calls to the insurance companies go:
"Hello and thank you for calling Express Scripts (or other insurance company)"
If you're calling in regards to a refill request press 1, if you're calling for a rejected claims press 2 etc etc  and many times instead of having you press a number they will have you say "refill" or "claims" this is often erroneous in itself because many times the robot on the other end can't decide what you're saying.

It will then ask you the RX or prescription number that you're requesting to receive information about, and thereafter it will ask you other information such as your NPI number, phone number, and name. Then hopefully after this you will be able to speak to an actual person about your claim that you have questions on.

When you get to talk to a person you then will be asked the questions over again and then asked what your problem is. Many times the person on the other end will either have you go about adding codes or changing things until you get a paid claim, or they'll change the information from the main server and then have you try to re-process the claim yourself. Other times this is not so easy and they will have you require a Prior Authorization from the doctor for the doctor to contact the insurance company.

Many times the insurance companies want the patient to call them with questions about their medications, but if I was a patient who had never dealt with any issues in the pharmacy before I would be dumbfounded as to how to answer the questions that the insurance company asks. For this reason the pharmacy staff needs to be well educated on issues and insurance information.