CareAffiliate Tips. Pharmacy. Authorizations Create and manage authorization requests for: *medical drugs

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1 Pharmacy Authorizations Create and manage authorization requests for: *medical drugs 1

2 Important! Training There are several helpful tools to assist you in learning CareAffiliate. Log in at hap.org and select the CareAffiliate Help link under Quick Links. You will find videos, training manuals and other helpful resources. Always check the Procedure Reference List first to ensure you need an authorization Log in at hap.org; select Procedure Reference Lists under Quick Links; Services that Require Prior Authorization List Logout - do not X out Always select Log Out and not the X when logging out of the application. Clearing a Member Name or Request Type If you realize you have entered the wrong Member Name or Request Type: Select Main Menu (from the navigation bar) Answer Yes to confirm you want to lose all changes Select Authorization Request to start over Attachments Medical records to support your request must be submitted via the Attachments link. Faxing attachments to HAP's Pharmacy Care Management at (313) slows down processing time significantly and therefore should only be used if you do not have an electronic file or your file exceeds the size limit (32 MB). Important Phone Numbers Issue Contact Hours Help with CareAffiliate including password resets Provider Services (866) Monday-Friday 8:00 a.m. 4:30 p.m. No Authorizations icon or system lockout Internet Application Team (313) or hapauth@hap.org Monday-Friday 8:00 a.m. 5:00 p.m. Emergent Admissions/Transfers assistance after 4:30 p.m. (313) , option 3 7 days a week; 24/7 2

3 What you need to 1. Patient s name and ID number have available before 2. Prescriber/ordering physician name and NPI number you begin entering 3. Diagnosis code the authorization 4. Procedure code 5. Brand, generic or chemical name. Note: You will need the generic or chemical name when you check the Services that Require Prior Authorization list. 6. Drug dose, units and frequency 7. Patient s chart/medical history Determine if: 1. The request requires an authorization 2. The request needs to be submitted through CareAffiliate or Pharmacy Advantage Check the Services that Require Prior Authorization List under Procedure Reference Lists when you log in at hap.org. Note: You will need the generic or chemical name. Look in the Key and if you see: PCM Denotes HAP s Pharmacy Care Management Submit request for authorization through CareAffiliate Select appropriate Request Type based on type of medication, condition, and place of service Request Types for medications are configured as Drug XXXXXxxxx, where XXXXX corresponds to specific medication category and xxxx to place of service. SPC Denotes Specialty Medication FOR COMMERCIAL MEMBERS: call Pharmacy Advantage for authorization at (800) or FAX to (888) FOR MEDICARE ADVANTAGE MEMBERS: Submit request for authorization through CareAffiliate. Please select the appropriate Request Type based on medication type and place of service. Request Types for medications are configured as Drug XXXXX-xxxx, where XXXXX corresponds to specific medication category and xxxx to place of service. The steps on the following pages are in the order that you enter information on the application. They offer tips on what to put in the field. 3

4 Member ID Member Name Request Type Profile Validation Enter 11-digit HAP ID number and the member name will auto populate Enter member name or click on magnifying glass to search The Request Type is essentially the place of service and service combined. It determines what fields auto populate throughout the authorization less data entry for you! To help you determine the appropriate Request Type, think about the following: What kind of provider (specialty) is prescribing the medication? (i.e., oncology, pulmonary disease) What is the diagnosis code? Will the drug be administered in the office or at a facility/infusion center as outpatient (use an infusion center Request Type for outpatient hospital settings) All Request Types begin with Drug (note: there are some requests that should only be selected by specific groups/providers) There are 2 grids to help you select the correct Request Type (a general grid plus a grid sorted by the brand name of drug). These can be found in the Pharmacy Services / Other Help Guides section on the CareAffiliate Help page. Look closely at the column to ensure you are selecting the correct Request Type. To search for a Request Type: Click on the magnifying glass next to Request Type Place your cursor in the Request Type Description field Enter *drug* and click Search and you will receive all drug Request Types (about 4 pages of results) Scan through the list and details and choose the appropriate Request Type If you realize you have entered the wrong Request Type: Select Main Menu (from the navigation bar) Answer Yes to confirm you want to lose all changes Start over by selecting Authorization Request Alert message appears after you select a Request Type. 4

5 Event Classification Select either Pre-Service or Pre-Service Urgent Contact Name The name of the NPI that you logged in with will default here. Change the name to the prescriber/ordering physician. Contact Phone Contact phone of the prescriber/ordering physician Enter the NPI or name of the logged in provider/facility (or someone who is set up in the same site). You may have to use the magnifying Requesting glass to search. (Note: if you are a physician office referring to an Provider/Facility infusion center, you will enter the infusion center as the Facility on the Service screen) Requesting Group Diagnosis Service From and To Dates Provider or Facility Provider Specialty Procedure (Low) Leave blank Enter code with or without decimal or search by clicking on magnifying glass. In the Description field, type a wild card * then at least 3 letters of a word then another wild card * and click search. Example: Enter *asthma* and it will return all results with asthma in the description Enter the start and end date for the drug treatment The location where the drug will be administered either in the office or at an infusion center or hospital (outpatient only) Specialty of prescriber/ordering physician. Begin typing the provider s specialty and options will appear for selection. Enter the procedure code. To search: Select magnifying glass In the Description field type a wild card * and at least 3 letters of the chemical drug name and another wild card * and then click Search Example: *inflix* (not *remicade*) Prescribed Dose The dose prescribed for the patient Choose the appropriate units from the drop down box Quantity Enter the billable quantity by: Referring to the Procedure (Low) field for the number of units Take the prescribed dose and divide it by the number of units For example: Prescribed dose: 300 mg Units: 10 MG Quantity = 30 (300 divided by 10) Per every For Total Enter duration and appropriate time from drop down Enter duration and appropriate length of time from drop down Auto populates 5

6 Assessment Assessments are required for all drug request. They are drug specific. All fields in green must be completed. However, it s important to read all of the fields. After you complete the Assessment you will receive a summary. If you have any changes to the Assessment, put them in Additional Notes. When you are finished with the Assessment, click Submit. You will obtain a Reference Number and Status for your request. 6

7 Additional s Reference Numbers Wild Card * Duplicate Authorizations A Reference Number does not mean the request is approved. You need to look at the status outcome (no action required, certified in total, pended, etc.). Use a wild card of * when searching as follows: Member name or provider name: type 5 characters and * Example: Johns* OR Lee * (note if a last name has less than 5 letters, use spaces) Diagnosis or procedure code/description: use the * before and after at least the first 3 characters of a code/description. Example: *123* OR *bar*; *inflix* Request Type Description: use the * before and after the first 3 letters of a description. Example: *inp* If you accidentally enter two identical authorizations, HAP nurses are able to see the duplicate and will cancel it. s for the Status Application You can search for an authorization(s) by one of the options below: Reference # Enter Reference #, then click Search Searching for Authorizations Service Begin date field Member ID or Member Name Enter Member ID or Member Name For any of the searches below, you must enter dates in either the Service Begin Date From and To or the Submission Date From and To (note: you can only enter a 30 day span of time) Requesting Provider ID Requested Provider ID Requested Facility ID Enter NPI of Requesting Provider (note: this is the Servicing Provider) Enter NPI of Requested Servicing Provider (note: this is the Servicing Facility) Enter NPI of Requested Servicing Facility Note: selecting Include Location as criteria checkbox limits records by address Same as Service From Date field on the Authorization 7