ATT019_XP007_PharmacyProviderBlock.pdf

Pharm-XP-007

Provider Blocks and the Provider Block Portal External Standard Operating Procedure

Original Publication June 2022 Revised March 2025

Introduction The World Trade Center (WTC) Health Program’s Clinical Centers of Excellence (CCEs) and Nationwide Provider Network (NPN) have a closed prescriber network. Only prescriptions written by enrolled prescribers will adjudicate through the Pharmacy Benefit Manager (PBM) system. If the prescription is not written by an enrolled prescriber, there will be a “Prescriber Not Covered” rejection at the point of sale (Reject 71 code). The CCEs/NPN are responsible for enrolling prescribers with the Program’s TPA contractor, Karna/GDIT, and ensuring they are oriented to the WTC Health Program prescribing policies. The PBM receives an updated prescriber file weekly from Karna.

Note: Not all providers through the Program are enrolled as “approved prescribers.” In these cases, members may be able to receive medical care by some providers; however, prescriptions written by that provider will reject at the point-of-sale.

Exceptions: Members enrolled in the cancer formulary have an open provider network.

Prescriptions for these members are not subject to this point-of-sale block.

Provider Block Queue (Provider Block Portal) Express Scripts (ES), the Program’s Pharmacy Benefits Manager (PBM), has developed a stand-alone system for the CCEs/NPN to review and make decisions on Reject 71 claims (“Provider Blocks”). The CCEs/NPN will only be able to view members assigned to their clinic in the Provider Block Portal.

Approving Authority The CCE/NPN Clinical Director has the authority to authorize “Prescriber Not Covered” blocks in the ES Provider Block Queue and may designate qualified staff members as authorizers as well. The CCE/NPN is responsible for training and monitoring the authorizer’s actions to ensure that policy and procedures are being followed appropriately. The CCE/NPN Clinical Director is ultimately accountable for all “Prescriber is Not Covered” actions by the CCE/NPN designated authorizer.

Process and Procedure Enrolling Prescribers

1. The CCE/NPN must inform WTC Health Program Support contractor (Karna/GDIT) if they want an enrolled provider to be in their CCE/NPN network, and if they would like them to also be enrolled as a prescriber. The clinic must specifically indicate that the provider is also a prescriber, or it will not be on the prescriber file to the PBM. The email address to use for provider/prescriber network management is WTCHP_Provider_Enrollment@gdit.com.

mailto:WTCHP_Provider_Enrollment@gdit.com

a. Note: Only providers included as authorized prescribers on the weekly prescriber files provided by Karna will be designated as such in ES’s system.

b. It is the CCE/NPN’s responsibility to continuously review and update the prescriber lists with Karna/GDIT.

2. Providers should only be enrolled as prescribers when:

a. The provider is going to be providing ongoing care to the member for their certified condition. In cases where a provider may be providing care for both certified conditions and conditions that are not WTC-related, it is recommended not to enroll the provider as a prescriber, since there is risk of prescriptions adjudicating that are not WTC-related.

b. The provider is not an emergency room or urgent care physician, surgeon, or other type of provider that won’t be involved with the members care long term.

c. The provider has been informed of the WTC Health Program requirements and rules and agrees to provide care under these provisions to the member.

Managing Point-of-Sale Provider Blocks All decisions made in the Provider Portal are specific to that member, drug, strength, and provider.1 For example, if the provider is approved for one prescription for six months, and another prescription by that provider is billed, that prescription will also require a decision in the portal.

1. If a member attempts to fill a prescription written by a provider who is not an authorized prescriber, the prescription will block at the point-of-sale with a message “Prescriber is Not Covered” (Reject 71 code).

2. The CCE/NPN staff with approving authority should log into the Provider Block Portal2 regularly to view the blocked prescription claims, review, and make decisions to approve or deny. The system will automatically log the user out after 30 minutes of inactivity.

3. Denying Blocks: Most provider blocks are not authorized by the CCE/NPN. This is most often because the prescription is not for the member’s WTC Health Program certified condition. The following are the steps to deny a block and remove a claim from the queue.

1 This change went into effect on September 29th, 2022.

2 Duplicate claims will no longer appear in the queue, only the most recent claim.

a. Select the claim and click on “block” for the PA Action option under Claim

Action

b. Do you want to block the drug for the member?

i. Yes (default): A negative PA will be added to the member’s profile for that medication, strength, and formulation. All future attempts to fill that medication, strength, and formulation will be blocked as “drug not covered.” Refer to the PA SOP (Pharm-XP-006) for further information.

ii. No: The current prescription will still remain blocked at the pharmacy;

however, future fills of that medication can get processed if prescribed by a different physician.

c. Decision Driver: select one of the following—

i. Not a WTC Health Program affiliated provider

ii. WTC Health Program affiliated provider, but drug is not WTC-related

iii. WTC affiliated provider. Do not intend to enroll as prescriber. Drug is not WTC-related.

iv. Other

d. Effective Date: Date the override should be effective from (could be today’s date, retroactive date, or future date3). “Allow” action has the calendar effective date pre-populated with the date of service of the claim. The calendar date is editable.

e. Expiration Date: Please enter the date any claims should be blocked through.

For an indefinite block, the date of 12/31/2099 can be used.

3 Future date will mean that the Rx will block until that date.

f. Comments: Comments will be prepopulated based on the Decision Driver.

Add additional detail if needed when using the “Other” Decision Driver.

i. Comments from the Provider Block Portal will also be visible in the

Customer Service Portal (CSP) in the Prior Authorization Summary Screen, under the Auth Description field. Example:

g. Then click Confirm (See Image Below). The claim will be removed from the

Provider Block Queue.

h. If no action is taken regarding a specific claim, the claim will continue to remain blocked from processing at the pharmacy (the Reject 71 remains), but the claim will automatically stop showing in the Provider Block Queue after seven days of inactivity. A timeout claim will result in an indefinite block on that claim. Should the pharmacy attempt to adjudicate the claim, it will block for a reject 71, but will not appear in the Provider Block Portal. Any timed-out claims will still show up on the claims history report if the report is run (see part 11 on page 7).

4. Approving Blocked Medications: In circumstances where a CCE/NPN determines a medication for a blocked prescriber should be allowed, an override can be put in place. Overrides should be done when:

a. The CCE/NPN has decided to enroll the prescriber and needs to allow the member to receive their WTC Health Program-related medications until the PBM system is updated, which occurs weekly, or

b. The CCE/NPN has decided not to enroll the prescriber because they do not meet one of the requirements above but has confirmed that the medication is for the member’s WTC Health Program-certified condition.

c. The following are the steps to override “Prescriber is Not Covered” blocks in the Provider Block Queue (See image below):

i. Under PA Action: select “Allow”

ii. Allow this PA to be applied to different strengths of this medication?

1. Yes (default): The medication will be approved in the future for the different strengths. Can also include the drug + strength (including multiple) + provider.

2. No: Only that strength of the medication will be approved.

Other strengths will block again.

iii. Decision Driver: select the following—

1. WTC affiliated provider. Do not intend to enroll as prescriber.

Drug is WTC-related.

2. WTC Health Program affiliated provider. Intend to enroll as prescriber.

3. Not WTC Health program affiliated provider. No intent to enroll the provider as the prescriber. Drug is WTC-related.

iv. Effective Date: date the override should be effective from (could be today’s date, retroactive date, or future date4)

v. Expiration Date: date the override should end

1. Limitations: up to one year

4 Future date will mean that the Rx will block until that date.

vi. Comments: document your rationale and the plans for enrolling the provider in the comments section of the Reject 71 claim in the Provider Block Portal.

5. Timed Out Claims: Reject 71 claims will be automatic deleted from the Provider Block Queue if no action is taken on a claim after seven days (the Reject 71 remains, but the claim will automatically stop showing in the Provider Block Queue after seven days of inactivity). A timeout claim will result in an indefinite block on that claim. Should the pharmacy attempt to adjudicate the claim, it will block for a reject 71, but will not appear in the Provider Block Portal. Any timed-out claims will still show up on the claims history report if the report is run (see part 11 on page 7).

6. Blocking Prescribers for Members on the Cancer Formulary: The cancer formulary has an open prescriber network. If a CCE/NPN has a prescriber that they want to block for future fills, they will need to submit a request to ES Client Service Center (CSC). CSC will update the member’s profile to ensure this individual prescriber will be blocked from future fills for that member.

7. Documentation: Notating the justification for the CCE/NPN’s decision in the comments section of the Reject 71 claims in the Provider Block Portal is a requirement for all decisions. The Comments section will auto-populate based on the Decision Drivers but can be modified if needed. Allowing auto-populated/standard comments will make review of Prior Authorizations in CSP easier to understand, as these will be visible in CSP in the Prior Authorization Summary Screen, under the Auth Description field (see screenshot on page 4 of this

SOP).

8. Notifying Members: The CCE/NPN should notify members when a “Prescribing Physician out of Network” block is being denied, or in cases where it’s approved but the member must follow up with an enrolled prescriber for further treatment.

9. Pharmacy Notification: The CCE/NPN can notify the pharmacy to reprocess the claim once approved.5 The pharmacy number is visible in the Provider Block Queue.

Note: when available, the CCE/NPN can notify the pharmacy via email if an email address is populated in the Pharmacy Email Notification field during Claim Action.

10. Searchable fields in the Provider Block Queue include the following:

a. Prescriber last name

b. Member ID (911 number)

c. Patient last name

d. Patient first name

e. Prescriber ID (NPI)

11. Claims history report: Generate a report of decisions made in the queue.

a. Criteria for report:

i. Approve, block, negative PA, timeout

ii. Start and end dates

5 ES does not get notification when a provider block has been approved and is unable to assist with notifying the pharmacy to reprocess.

b. Generates Excel sheet with all decisions based on the criteria including claims detail, decision details, and user that made the decision. Note: The report generation has a three-month data limit when pulling the report.

Multiple date ranges can be requested to create a longer time frame, however, must be done in three-month increments.

Quality Controls The PBM will report on Provider Blocks in their semi-annual reports, including the authorizations and denials, for auditing purposes. They will also be reported in the CCE/NPN annual CCE/NPN Pharmacy Evaluations. The CCE/NPN should carefully document rationale for decisions in the Provider Block Portal related to authorizing or denying prescriptions from providers that are not authorized prescribers.

CCEs/NPN should regularly audit these decisions to ensure they are made based on their internal and WTC Health Program’s policies and procedures. CCEs/NPN should also periodically analyze their provider lists to ensure they are up to date.

Revision History March 2025 As a result of an additional new enhancement separate from the above, provided further updated language about indefinite blocks from timed out claims, and how they can still be seen from claims reporting. Also updated language to reflect Express Scripts branding change, and expanded on the title of the SOP. Minor formatting and font changes to text.

July 2024 Added changes to align with new provider block enhancements that went live this year, and provided additional clarity and details on certain sections.

July 2023 Minor technical changes that don’t affect the content of the SOP.

March 2023 Updated to reflect PBM transition.

June 2022 Initial publication.