New Tech at Walgreens: I Need Help with Handling Insurance Problems...

by Joseph
(Florida)

Prescription Insurance Rejection Questions...

I just started working at Walgreens and I don't know what half of the insurance problems are like what steps am I suppose to take in order to resolve them, like for example a prior authorization or a refill too soon or when to contact an agency?

Answer:

This is a very good question. A good part of how to resolve these issues is probably in your handbook or in material that Walgreens employees may have given you when you started. As I have never worked for a Walgreens, I am not sure how they do things. However, I did just answer a question about Walgreen's Intercom Plus Software and you can read about it here: Pointers/Tips on Intercom Plus.

A few of the most common insurance rejections you will encounter include: Prior Authorizations, Refill Too Soons, DUR (or Drug Utilization Review) rejections, and Filled After Coverage Terminated rejections.

First, it would be a good idea for you to read about Prescription Insurance:
Prescription Insurance Basics.

I have a page on this site on Prior Auths:
Prior Authorization Basics.

Resolving Prior Auths involves:
1.) Notifying the patient. At this point, the patient is given the choice of paying out of pocket for the prescription (some people actually do do this) or waiting for the PA to be approved. At this point, if they decide to wait, the prescription usually goes “on file” (or “on hold”) and is not filled.
2.) Calling or faxing the prescriber’s office and notifying them so they in turn can call/fax the insurance company and provide them with the clinical information they need.
3.) Running the prescription again at the patient’s or prescriber’s request. Sometimes prescriber's offices will notify the pharmacy once they hear from the insurance company that the PA has been approved. Often when they are notified, they are also told how long the PA is good for, for example, for 6 months or 1 year. I usually make a note of this on the patient's profile if I have been given it. Sometimes the patient will find out from the doctors office. When this happens, the patient usually calls the pharmacy.

And a Page on Refill Too Soon Rejections:
Refill Too Soon.

DUR Rejects are different from the previously mentioned rejections. Sometimes, depending on the insurance company, entering override codes (Walgreens will have a copy of these or the pharmacist/other techs should know these) will get the insurance company to pay for a claim. Other times, a DUR Rejection means calling up the insurance company and they can enter the codes on their end or provide you with the codes to enter on your end. It is a good practice to stay on the phone with an insurance representative until you receive a paid claim on your end of things. Also, sometimes if you go to the insurance companies website, they might have the override codes listed there as well.

As far as “Filled After Coverage Terminated” rejections go, this usually means that the insured patient is no longer covered by that insurance company. The pharmacy I work at has subscribed to a website called Emdeon and we are able to look up a customers insurance (if they have coverage) there and enter it into our software and get the medication covered for them, sometimes without them even knowing there was a problem or even providing us with a new insurance card. Maybe Walgreens has a similar database that they can tap into in this situation.

I hope this information has helped answer your question. It is a great question and if you need any more help or have any other questions, feel free to ask them!