Pharmacy Service Center (PSC) Call Handling

An important message to Customer Advocates

Topic Pharmacy Service Center (PSC) Call Transfers

What One Rx CSAs should not be calling over to the PSC (Authorizations) unless it is
should I absolutely necessary.
do

How Advocates should only be calling over to the PSC in qualifying circumstances. 
should I Many times, the PSC is being contacted for matters that they cannot assist with
or that could have been handled by the Retail Rx Advocate in the first place.
do it
PSC Associates CAN do the following:

1. Process prior authorization or precertification from provider's offices received

through phone, Prompt PA, or fax.  They may also speak with pharmacists.
2. Make an outreach call to the provider's office to attempt to complete prior
authorization or precertification over the phone (Exception if a fax only drug).
3. Answer questions about prior authorizations for internal CSAs and providers
only.
4. View appeals in OneView (As can Retail Rx CSAs.  See Below.)(Never
transfer appeals).
5. Take requests for Peer-to-Peer reviews from doctors.
6. Handle calls related to the Argus Error Codes that would require a medical
necessity review (prior authorization).

PSC Associates CANNOT do the following:

1. Take a prior authorization or precertification from customer (Pharmacy

Services does not handle customer calls).
2. Take appeals from customers or provider's offices over the phones (Appeals
from provider's office must be faxed in).
3. Handle CHD calls in any capacity.
4. Handle benefit questions.
5. Directly contact the National Appeals Organization.
6. Take escalated calls from customers.
7. Handle calls that are not related to a medical necessity review (prior
authorization).

Essentially, this means that Retail CSAs should only be reaching out to the
PSC if the issue resides within the "CAN" section.  It would not do anything to
advance the call if the issue in question is something that the PSC would not be
able to handle.  That said, there are some scenarios that frequently crop up
that may or may not require interaction with the PSC.

Appeals
Appeals are a unique item in that they are essentially inaccessible to the PSC
once the PA has moved into the Appeal status.  Simply put, when a PA is
upgraded to an Appeal, it is handled by the Appeals Unit, which is separate and
distinct from the PSC.  PSC reps have no more access to review Appeal status
than Retail Rx does.  The Appeals Unit handles their own matters internally and
they communicate with the rest of Cigna by updating the call notes in OneView
with the status and/or outcome of said Appeal.  This means that the PSC has
no more ability to view the status of an Appeal than Retail Rx does.  If there
are no notes in the OneView Appeals tab regarding the appeal, then there
essentially is no information available regarding it, so a call over to the
PSC will not provide any additional information.  However, this only applies
to 215 customers.  If the customer has an appeal and is 518/519, the CSA will
need to call over to the Facets/Payer Customer Service. These calls go not go
to PSC.

Missing PA/PA Not on file

If you are looking in PAHub for a PA and cannot find anything on file,
there is no reason to contact the PSC.  They do not have special access
to see anything that we do not.  Please advise the caller that there is no PA
on file and work the call from there.  You can always offer to call the provider
for the customer or fax the form to the provider, so these will likely be better
courses of action to follow. At this time, all PA requests should be viewable in
PAHUB, so it should not matter if they are 215, 518 or 519.

Denied PA
If a PA is denied, the reason codes will be listed in the Full Report in PAHub. 
Any Retail Rx CSA with PAHub access will be able to view the Full Report
and therefore can view the outcome.  Most of the time, this information can
be relayed to the caller without needing to call over to the PSC.  The only
circumstance that may warrant a call over is if there is a glaring
discrepancy in the PA request/outcome.  For example, if the PA was denied,
but the doctor clearly indicated medical necessity that might have gotten it
approved then this is probably worth calling over.

Approved PA, but no override in Argus

If a PA is showing approved in PAHub, but cannot be found in Argus, then the
PSC should be contacted to have it loaded.

Multiple Error/Denial Codes

PA Requests are often considered a “one shot deal” in the sense that they are
typically loaded to only account for specific error codes.  If more error codes
show up down the line, then under most circumstances, a new PA is required. 
For example:

-A PA is approved for code 477, but three months later the 146 code begins to
deny the medication.  This would need a new PA.

-A PA is approved for 082, but months later the doctor changes the dosage and
now there is a 029 error.  This would need a new PA.

-A PA is approved for 082 and 159 on the first shot, but it fails to pay through
despite having approval.  The PSC should be contacted to have the override
fixed.

Strength Changes
As per the workflow in PIT, if a medication has been approved at one strength
level and the doctor is now changing it, a new PA is NOT NECESSARY
provided that is the only change.  The authorization can be updated to allow for
the new strength to pay through.  However, if there are NEW edit codes in
Argus being introduced by the strength change, then a new PA is required.

Supplemental Information
 This section will contain miscellaneous information that may help with general
call handling in an effort to further prevent us having to outreach to the PSC for
assistance.

Appeals
Customers may ask what an Appeal actually is or what is actually being done
during an appeal.  An Appeal is essentially an escalated review of a denied PA
request by Cigna's Appeals Unit.  The right to appeal is granted by federal law
and when a PA request is upgraded to Appeal status it means that it is being
heavily scrutinized to ensure compliance with all state and federal laws.  An
Appeal is NOT a guarantee of coverage.

Appeals – Expedited Requests

All appeals can request expedited status, however, there is no guarantee it will
be awarded.  If the request is denied, the provider will receive communication
indicating the denial.

Appeals – Second Level

Some plans and/or states do allow for a “second level” appeal to take place,
but this is not universally available.  If the state or plan in question allows for
this to take place, all of the necessary correspondence will be provided after
the first appeal is denied.

Appeals – State Specific Criteria

The Appeals Unit works in compliance with all state and plan-specific
mandates, however it is important to note that in most circumstances this will
only apply to NON-ASO plans.

Peer-to-Peer
A Peer-to-Peer (P2P) is not the same as an Appeal.  At its simplest, a P2P is
an open dialogue over the phone between the customer’s doctor and one of
Cigna's staff doctors or medical directors.  If the outcome of the P2P review is
still a Denial, the PA request CAN still be sent to Appeal level for further
consideration.  Please keep in mind that if we are advising our callers of a
Peer-To-Peer, that more often than not it will NEED TO BE SCHEDULED
and not be instantly available.  There is no guarantee that a doctor can call in
and immediately get a medical director on the line.

Prior Authorization – Online Prior Authorizations

Cigna now offers the option to submit and check status of prior authorizations
online. This will cut down on the turnaround times. If a provider states they
cannot complete a prior authorization over the phone or wants a form faxed
advise the caller of our online option, PromptPA. It is free and easy to use.
Once the provider completes the request on PromptPA, the prior authorization
is automatically inputted into our system and the provider can check status of
the authorization. https://cigna.promptpa.com/

Prior Authorization – Second Request

If a PA Request is denied, the doctor’s office does not necessarily have to
request an appeal or peer-to-peer.  They can, alternatively, simply send in a
new PA request with additional info.  Bear in mind that this will result in the
second request being considered as an entirely new review, but it still may be a
faster option than those others.

Prior Authorization – State-specific Forms

In CM, there is a listing of state-specific PA forms.  These MUST be sent to
providers in the respective state. The PSC will void a request is not sent on the
 state specific form and one is required.

Prior Authorization - Texas Mandates

The State of Texas requires that all PA requests be completed by Cigna's
clinical staff.  In essence, this means that all PA requests are being reviewed
by the highest level of Cigna's medical directors.  In turn, all denied requests
require that Cigna contact the provider’s office to offer a Peer-To-Peer request
within 24 hours.  The doctor’s office then has 24 hours to respond before the
request is properly denied.  At that point, a P2P is still available, but it would
have lost priority.  Likewise, the decision can still be appealed as normal.

Step Therapy Approval Duration

Routinely, when Step Therapy is approved, the approval duration is Indefinite
or “life of plan”; however this is not always the case.  On occasion, a Step
Therapy approval is finite and may only last for 6 months to a year.  In these
cases, this was a clinical decision that was made based upon the information
from the customer’s doctor.  For example, the doctor may indicate that they are
switching the customer to a different medication after 6 months.  In this case,
the PA approval would likely only be for 6 months.  This means that if the
therapy was to resume at a later date a new PA would be needed.

Contact Information for PA Requests/Submissions

Online
https://cigna.promptpa.com/

Product One Rx

Resource This document, the links contained within and the PIT.
s https://centralhub.cigna.com/team/pscee/PIT/default.aspx

If you have any questions, or need help with this issue, or anything else, please
contact your coach.