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Member is invalid. |
Verify
submitting the following:
• Express Scripts
• 12-number ID
• Group number (GMEA)
• Date of birth (Refer to the DOB on the card.)
• member's full name (first and last)
• Gender
Determine
whether member has met his or her spenddown amount.
• If member has not met his or her spenddown amount,
he or she is not eligible; refer to caseworker.
• If member has met his or her spenddown amount
and is still rejected, send a UCF form with supporting documentation.
If claim is still rejected, refer
member to ACS Customer Interaction Center at 404.298.1228 or toll-free, 800.766.4456.
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|
Member has termed. |
•
Verify that member presented a current card.
• Determine whether member has other primary coverage.
If claim is still rejected, refer member to ACS Customer
Interaction Center at 404.298.1228 or toll-free, 800.766.4456.
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Prescriber is invalid.
|
Submit
Georgia license number.
•If number is unavailable, please go to the Georgia
Composite State Board of Medical Examiners website.
Exceptions will be made for prescriptions written in Georgia
for:
PDO300 = Podiatrists, Dentists, Optometrists
GHS300= Grady Health System Hospital, Clinics, Emergency Rooms
AOH300= All Other Hospitals, Clinics or Emergency Rooms
AOS300= All Out-of-State Providers
ANP300= All New Physician License Number (granted within the
last 60 days)
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Prior authorization is required. |
•
Contact Express Scripts’ provider line toll-free at 877.650.9340
• After prior authorization number is obtained, resubmit claim
online (no UCF required). |
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Refill is too soon. |
•
Determine whether member is obtaining a vacation supply.
If so, it is not covered.
• Enter "99888" into the prior authorization field for lost,
stolen, or mid-month dosage change. Override is allowed at
a maximum of six times per calendar year per drug. Cannot
be used for prior authorization overrides or therapy limits.
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The prescription is high cost.
|
•
If cost is between $0 and $2,999.99, submit online.
• If cost is between $3,000.00 and $9,999.99, call Express
Scripts at 877.650.9340 for prior authorization, then submit
online.
• If cost is more than $10,000.00, submit a UCF.
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You need an automated override code. |
Submit
one of the following codes:
• 11111 (Nursing facility members exempt from copayment)
• 22222 (Pregnant women exempt from copayment)
• 99888 (Emergency prescription exempt from copayment)
• 55555 (Non-nursing home members to override monthly
prescription limit)
• 66666 (Nursing home members to override monthly
prescription limit)
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