Pharmacy Insurance Rejections Questions-Is the pharmacy required to call my prescription insurance when there is a non-matched cardholder ID rejection?

by Frustrated
(Tallahasee, Florida, USA)

Hello, I went to CVS Pharmacy and my insurance card was rejected 5 times for a non-matched cardholder id. Is there any set limit for a rejected card before the pharmacist calls the insurance provider? Is he required to call the insurance provider about non matched cardholder IDs? Also, the pharmacist refused to give the insurance agent the phone number so she could talk to him directly? Is there anything else I can do about this? I already filed a complaint with CVS about the incident.

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There is no set limit for a rejected card before Pharmacy Staff should call the Insurance Company
by: David

Hi, Frustrated,
I can certainly understand that you are feeling annoyed and angry that your insurance isn't working so that your prescriptions will be covered. This is a difficult situation, however, it is a situation that pharmacy techs and pharmacists face just about every single day at the workplace.

I'll try to answer your questions one-by-one.

First, No, there is no set limit of occurrences where someone's insurance is rejected before one of the pharmacy employees are supposed to call the insurance. Here's the rub-if your insurance changed, then the card that is on file, or the card that you bring in to use to get your medications covered is probably not going to work. Also, every time that the pharmacy software sends a request to bill insurance, the pharmacy incurs costs for every transaction that is processed, even if the billing information is wrong. It is not the pharmacy employees' job to find out who your insurance is now through and to make sure that they have the most up-to-date information. As the patient, that is your job. Many times pharmacy employees have to go on wild-goose chases to chase down the most up-to-date patients and customer's insurance information. This wastes a lot of these employees' time and resources which should be spent elsewhere. As a customer, it is not the pharmacy's job to ensure that you have the most up-to-date information. Customers must provide their information, and if not, we as pharmacy techs and pharmacists cannot effectively do our jobs.

To answer your second question, Is he required to call the insurance provider about the non-matched cardholder IDs? Well, what do you think? If there is a non-matched cardholder ID rejection, that means that with the demographic information that is on that card, there is no coverage associated with it. What would be the point of calling the number on the back of that card? I guess that it is possible, if the insurance is still with that company, that the pharmacy may find active coverage under a new cardholder ID. That does happen sometimes. But more times than not, the insurance carrier changes, in which case calling the insurance will lead to a dead end. The insurance will likely tell the tech or pharmacist that there is no active insurance coverage with that patient, date of birth, address, and other demographic information. So not only has the customer wasted his time, more importantly, the customer has wasted the pharmacy techs time to chase down information that we already knew, namely, that the patient is not covered by that insurance any longer.

Your next question, Is he required to call the insurance provider about the non-matched cardholder IDs? No, absolutely not. Patients are a lot more empowered nowadays. The patient can be a responsible party and they can call to find out what their coverage is or is not. Don't waste the pharmacy's time chasing their tails. They have lots of patients and customers. Don't make it harder for them to do their jobs. Patients need to start bearing some responsibility for their own insurance coverage or lack thereof.

Your next question, "Also, the pharmacist refused to give the insurance agent the phone number so she could talk to him directly?"

That is interesting. I'm not completely sure what you mean. At the beginning of every call to an insurance company, the insurance representative asks for the pharmacy's NPI or NABP number. This identifies the specific pharmacy that is calling the insurance. Usually, the pharmacy information most likely is pulled up on the insurance company rep's computer screen, so they already have the pharmacy's phone number to call them back in case of a disconnection. You, as the customer, as the patient, can call your insurance directly. I mean, why not? Cut out the middleman! Find out who your insurance is with, and ask them for the Pharmacy BIN number, the Pharmacy ID number, the Pharmacy PCN number, and your person number. These 4 pieces of information will help the pharmacy process your insurance claim correctly so your medication cost will be covered if you are providing the correct information to the pharmacy.

Is there anything else you can do about this? I don't think there is anything more I need to say about this. Filing a complaint with CVS is not likely to go anywhere. If you want to get some employees fired, then have at it. It's not likely that that type of complaint would get someone fired, but whatever floats your boat.

Clearly, this question comes from a misunderstanding about how prescription insurance works and how pharmacies work.

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