Insurance Rejection Scenarios

Scenario 1

A patient brings in a prescription for Singulair 10 mg for the pharmacy to fill, and decides to wait for their prescription. After obtaining all of the patients PHI and entering all the data into the computers, the technician proceeds to enter the prescription and adjudicate a claim to the patients insurance. Upon submission, the technician receives a rejection message stating that the patients is over the age of 18 and the insurance formulary requires a prior authorization. (Certain insurance companies will only cover Singulair for adults if doctors diagnose the patient with a specific diagnosis, such as Asthma)

a. What steps need to be taken to begin the process of resolving the rejection?

b. Who do you need to contact or notify, who completes the notification, and how are the individuals notified?

c. What other options might be given and to whom?

d. How long should this process take, on average?

Scenario 2

A patient brings in a prescription for the medication Xarelto 15 mg, and states that he will return later to pick up the medication. The patient has had prescriptions filled at the pharmacy before and all information in the computer is current. After entering the prescription in the computer and submitting the claim to the insurance, you receive a rejection stating drug not covered. The patient was diagnosed with atrial fibrillation and was recently discharged from the hospital. It is important that the patient take the medication and comply with home medications. The cost of the medication without insurance (cash price) is about $300.00. However, the patient does not have enough money with them to pay the cash price. (There are certain drug companies that offer discounts or free trials for medications)

a. What steps need to be taken to begin the process of resolving the rejection?

b. Who do you need to contact or notify, who completes the notification, and how are the individuals notified?

c. What other options might be given and to whom?

d. How long should this process take, on average?

Scenario 3

A patient brings in a prescription for Norco. The patient seems to be in pain and in a hurry to obtain their medication. After entering all of the patient information and running the prescription through the insurance, you receive a rejection stating: Early fill (was filled at another pharmacy on *date of three days prior to today*). The medication was written with the following directions: Norco 7.5 mg/ 325 mg, dispense # 60 tablets, sig: 1 tab QID prn for pain. The same medication and directions were filled at another pharmacy 3 days ago, but from a different doctor. After speaking to the patient, they inform you that they are willing to pay cash for the medication because they need it. Upon further inspection of the prescription, you notice that there might be an issue with the DEA # as well. The DEA # was invalid. The technician was told by the doctor's office that a script pad was recently stolen from the office and that the patient in question was not prescribed the above medication.

a. What steps need to be taken to begin the process of resolving the rejection?

b. Who do you need to contact or notify, who completes the notification, and how are the individuals notified?

c. What other options might be given and to whom?

d. How long should this process take, on average?

Scenario 4

A patient brings in a prescription to be filled by the pharmacy and will be back in a few days. The patient has had many prescriptions filled at the pharmacy and is helped by a familiar technician. The technician enters the prescription promptly and bills the insurance. After adjudication, a rejection appears stating coverage terminated / please check new card or verify ID and group. The patient did receive a new card in the mail recently but did not believe that any information had changed. The patient has also had the same medication filled each month for the past year.

a. What steps need to be taken to begin the process of resolving the rejection?

b. Who do you need to contact or notify, who completes the notification, and how are the individuals notified?

c. What other options might be given and to whom?

d. How long should this process take, on average?