by Amber Steely | Apr 20, 2023

[SYSTEM] is a user-friendly tool that allows you to quickly and efficiently manage workers’ compensation prescription allowances. This guide will walk you through the basic steps for using [SYSTEM], including:

Key concepts,
Navigating the interface,
Allowing a drug,
Disallowing a drug,
Overriding processor rejections.

Let’s get started!

Key Concepts

Let’s get familiar with some key concepts to boost your understanding of the system. Take a look at the list below.

Action – Used to classify authorizations and specify whether a prescription claim is allowed or disallowed. Used in conjunction with action values.
Action value – Tags that describe whether a claim is allowed or disallowed.
Rejection Tracking System (RTS) number – Serves as an identifier for claims processor rejections that are hard-coded in the system.
Override Rejection Tracking System (OVRTS) code – Utilized to bypass or override hard-coded claims processing behaviors when necessary.

Navigating the Interface

[CONTENT WILL GO HERE]

Allowing a Drug

To allow a drug:

From the Blue Diamond main menu, select the Patient tab.
Enter the patient’s name in the Search By Name tool. A list of patients will display on the screen. Choose the patient you need from the list.
Go to the left sidebar menu and click the down arrow next to Prescriptions to view the available options.
From the options listed under Prescriptions, select [OPTION].
Enter the name of the approved drug in the Drug Name field [or search by NDC].
Click on the arrow next to the Action field to open a dropdown menu. Choose a relevant action from the list.
Expand the action value dropdown menu and select Allow.
Fill in any other relevant fields, such as the start and stop date, day supply, and quantity allowed.
Click [ADD BUTTON].
[The allowed medication will display in a table on the screen.]

Disallowing a Drug

To disallow a drug:

From the Blue Diamond main menu, select the Patient tab.
Enter the patient’s name in the Search By Name tool. A list of patients will display on the screen. Choose the patient you need from the list.
Go to the left sidebar menu and click the down arrow next to Prescriptions to view the available options.
From the options listed under Prescriptions, select [OPTION].
Enter the name of the approved drug in the Drug Name field [or search by NDC].
Click on the arrow next to the Action field to open a dropdown menu. Choose a relevant action from the list.
Expand the action value dropdown menu and select Deny.
Fill in any other relevant fields, such as the start and stop date, day supply, and quantity allowed.
Click [ADD BUTTON].
[The disallowed medication will display in a table on the screen.]

A default rejection message will be returned to the pharmacy by the system if a claim for the disallowed drug is submitted.

Overriding Processor Rejections

Our system has a library of over 450 pre-programmed rejection codes. Hard-coded rejections within the claims processor are assigned a Rejection Tracking System (RTS) number. Rejections from the processor are viewable in the rejection queue and will include the RTS number for reference.

We have a small subset of override codes, called Override Rejection Tracking System (OVRTS) codes, that correspond to RTS numbers and can override these rejections if needed. If the available OVRTS codes do not meet your needs or if you require additional OVRTS codes to override processor rejections, please let us know. We would be happy to add them to our library.

Scenario

A patient has been prescribed an antidepressant. It is not on the group formulary. The adjuster needs to approve a drug in this class for a patient.

To approve the antidepressant:

From the Blue Diamond main menu, select the Patient tab.
Enter the patient’s name in the Search By Name tool. A list of patients will display on the screen. Choose the patient you need from the list.
Go to the left sidebar menu and click the down arrow next to Prescriptions to view the available options.
From the options listed under Prescriptions, select [OPTION].
Enter the name of the approved drug in the Drug Name field [or search by NDC].
Click on the arrow next to the Action field to open a dropdown menu. Choose the action called [NAME].
Expand the action value dropdown menu and click Allow.
Fill in any other relevant fields, such as the start and stop date, day supply, and quantity allowed.
Click [ADD BUTTON].
The allowed medication will display in a table on the screen.

Formulary Policy
	A/N	Description	Action	Selection	Rejection
	30000-000	Approved Drug Authorizations
✔	30000-005	CYCLOBENZAPR	GPI: 7510005010	DRUG: Y
✔	30000-010	TIZANIDINE	GPI: 7510009010	DRUG: Y
✔	30000-015	GABAPENTIN	GPI: 6610052500	DRUG: Y
	89999-900	Plan Defaults
✔	89999-997	Max Cost 1000	Over: 1000	COST: N	78 Cost Exceeds Maximum
✔	89999-998	DS Max 30	D/S Over: 30	DAYSUP: N	19 Missing/ Invalid Days Supply
✔	89999-999	Closed Formulary		DRUG: N	75 Prior Authorization Required

Key: A/N = Authorization Number, D/S = Day Supply, N = No, ONFORM = On Formulary, Y = Yes

Override Individual Actions with Separate Authorizations

These are the three actions we need to override based on the policy described in the table above:

Allow Drug (DRUG) to approve the drug, Gleevec (A/N 89999-999).
Day Supply (DAYSUP) to approve the submitted day supply over 30 days (A/N 89999-998).
Allow Cost (COST) to approve the submitted cost over $1000 (A/N 89999-997).

Since the claim in our scenario is for an individual patient, we will add authorizations in the Patient context. Three separate Patient authorizations need to be created to override each action set on the policy’s plan defaults. They are shown in the next table.

Patient Authorizations
A/N	Description	Action	Selection	Rejection
13000-001	Gleevec cost OK	COST: Y	Cost Up To: 5000
13000-002	Gleevec D/S OK	DAYSUP: Y	D/S Up To: 60
13000-003	Gleevec OK	DRUG: Y	GPI: 66100525

Key: A/N = Authorization Number, D/S / DAYSUP = Day Supply, N = No, ONFORM = On Formulary, Y = Yes

Summary