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AaNeelCare® – Part D coverage Determination

AaNeelCare® helps you to make the necessary documentation like prescription drug information, the reason you're appealing the denial, the prescribing doctor's information etc. and follow the steps involved in the process coverage determination and redetermination.

AaNeelCare® – Part D coverage Determination

Medicare Prescription Drug Plans are also known as Part D plans. They help you pay for prescription drugs. Medicare along with insurance companies and other private companies offer many drug plans. One can choose the plan by comparing with other available plans and based on the prescriptions you take and select a plan that is most effective for you.

We at AaNeel care have designed a module for Part D coverage after careful consideration of all the appeals process involved in it.

Our tool is built based on Part D coverage workflow process as follows:

When the Patient presents the Prescription to the Pharmacy, the prescribed drugs in the prescription will be approved after verifying the Insurance of the member if the Drugs are:

• within the Formulary
• and meets the QL(Quantity Limit), PA criteria and is not in Step Therapy

If not, the Pharmacy (POS – point of sale) will reject the prescription if the Drugs are:

• outside the Formulary(not listed in the Insurance Formulary)
• Drugs that may require Prior Authorization due to age restriction, any Co existing disease, etc
• Within the formulary but still not within the Quantity Limit. For eg., if only 60 is the QL for the particular Drug and if the doctor had prescribed 100, then it will be rejected.
• Within the formulary but still requires Step Therapy. For eg., For a patient to start taking a Tablet C he has to be on Tablet A for few days/months, then on Tablet B for few days/months and finally start with Tablet C.

Once the Pharmacy rejects the Prescription, it informs the Patient about the rejection as well as to the Doctor stating that authorization is required.

After the Rejection at the POS, either the Patient or the Doctor can initiate a Coverage Determination. For this, the Insurance company would require more documents from the Physician and it also sends a Questionnaire( Coverage determination form) pertaining to the same. The Doctor should fill in the questionnaire and fax it. If it is on urgent basis, then the questionnaire will be filled out by phone and faxed later. This will contain questions like what was the DX? What was the blood test report? Etc.,

The clock starts ticking as soon as the Insurance Company has all the required information from the Doctor that is sufficient enough to make a decision. The time does not start until the Insurance Company has sufficient information to make a decision.

For Formulary drugs, there are certain criteria for Authorization, if these are met, it will be approved as they will not need any further information.

For Non Formulary drugs, the insurance will question the provider whether he had tried any substitute drugs that is in formulary which is similar to this drug that is expensive and non-formulary. They will require more information if it is a non – formulary drug. If there is a drug equivalent to the non-formulary drug in the Formulary drug list, the insurance will deny the drug. In such cases, the doctor can prove by submitting blood reports stating that he used drugs in the formulary and it didn’t help the patient. The Insurance Company may have to approve in such cases.

Once the Insurance Company receives the entire questionnaire that is filled by the Doctor, the coverage determination will be made. The coverage determination can be either Approval or Rejection of the Drug. The Standard process is 72 hrs and the Expedited process is 24 hrs in the coverage determination process.

If the drug request is approved, the physician (By fax & Letter) and the Patient (by phone & letter) are verbally informed about the approval within 24hrs in case of expedited process and within 72 hrs in case of Standard process. For Standard process, there will be an additional 72 hours for notifying by letter to the Physician and the Patient. For Expedited (Urgent) process, there will be an additional 24 hours for notifying by letter to the Physician and the Patient. The system will have templates of the letters that need to be sent to the Patient and the Physicians. The name of the Physician, patient, Drug name, dose, date, etc., has to be filled in and the letter sent.

If the drug request is rejected, the physician (By fax & Letter) and the Patient (by phone & letter) are verbally informed about the rejection within 24hrs in case of expedited process and within 72 hrs in case of Standard process. For Standard process, there will be an additional 72 hours for notifying by letter to the Physician and the Patient. For Expedited (Urgent) process, there will be an additional 24 hours for notifying by letter to the Physician and the Patient. The system will have templates of the letters that need to be sent to the Patient and the Physicians. The name of the Physician, patient, Drug name, dose, date, etc., has to be filled in and the letter sent. This letter also states that the patient has the right to appeal, how to appeal, to whom to appeal, the documents required to appeal, the reasons for the rejection, the time frame within which they have to appeal, etc

Testimonial

AaNeelCare® is very as customized and individualized. They analyze and assess our needs before presenting us with the required modules for our setting. Depending on for what healthcare environment do you need this technology, whether it is a physician office using only EMR or a hospital, and then they customize the product to those needs. They also scale the requirements as per our demands as we grow. AaNeelCare® provided us with all the things we were looking for. They had the modules, they had the integration, they had the right technology, and they were the kind of company we liked working with. Their customer support is awesome.

AaNeelCare® is very user friendly. You are able to move from one screen to another quickly. There is no much clicking required as in other EHRs , we’ve worked with.

The functionality of this product is excellent. It provides efficiency and is user friendly. It is well-designed to capture the modern technology we use today.

This software is user-friendly enough for each person in your office, even for the not so computer savvy users! Most of the modules are simple and easy to use, all the icons are simple to navigate and make life easier.

AaNeelCare® has been absolutely a pleasure to work with. We could not have moved as quickly as we have without AaNeelCare®’s constant support and monitoring of our progress as we implemented this product.

I'd highly recommend AaNeelCare® to Physicians and hospitals for this allows complete and precise maintenance of patient records, saving lots of time and money. The software not only helps in management but also in improving the quality of medical practices and processes as it reduces manual errors.

Thank you all, for an absolutely fantastic product that meets all our needs under one roof that is so incredibly logical and user friendly. I’m so happy that there is something out there that actually works, even when compared to big names in the market. If all my fingers were thumbs I would give 10 thumbs up!