Attachment J.27 - Provider Blocks SOP (Draft).pdf

SOP TITLE: Provider Blocks SOP Number [Insert Unit Identifier]01

Version Number V1.0

Effective Date 06/01/2022

Date Last Reviewed 05/10/2022

SOP Owner Pharmacy Benefits Unit

1. INTRODUCTION

1.1 Background

The WTC Health Program’s Clinical Centers of Excellence (CCEs) and Nationwide Provider Network (NPN) has a closed prescriber network. Only prescriptions written by enrolled prescribers will adjudicate through the pharmacy benefit management (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. The CCE/NPN are responsible for enrolling prescribers with Program’s HPS 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.

Prescriber Block Queue: Express Scripts, the Program Pharmacy Benefits Manager (PBM), has developed a stand-alone system for the CCE’s/NPN to review and make decisions on Provider Blocks. The CCEs/NPN will only be able to view members assigned to their clinic in the prescriber block queue.

Approving Authority The CCE’s/NPN Clinical Director has the authority to authorize “Prescriber Not Covered” blocks in the ESI Prescriber 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’s/NPN Clinical Director is ultimately accountable for all “Prescriber is Not Covered” actions by the CCE/NPN designated authorizer.

2. PROCESS AND PROCEDURE

2.1 Enrolling Prescribers

If 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. You 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

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

Providers should only be enrolled as prescribers when:

mailto:WTCHP_Provider_Enrollment@gdit.com

• 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.

• 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.

• The provider has been informed of the WTCHP requirements and rules and agrees to provide care under these provisions to the member.

2.2 Managing Point-of-Sale Provider Blocks

All decisions made in the Provider Portal apply to the members entire prescription profile. For example, if the provider is approved for one prescription for 6 months, that approval will apply to all other prescriptions for the member written by that provider in that 6-month period.1

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”

2. The CCE/NPN staff with approving authority should log into the Prescriber Block Queue regularly to view the blocked prescription claims, review, and make decisions to approve or deny.

3. Denying Blocks: Most prescriber 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,

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

b. Decision driver: select one of the following2 –

i. Provider is deceased

ii. Not an authorized provider

iii. Physician dispense not allowed

iv. Other

c. Effective Date: Today’s date

d. Expiration Date: Do not enter time limit. All blocks would be ongoing.

e. Comments: document your rationale in the comments section of the Prescriber Block Queue.

f. Then submit (See Image Below). The claim will be removed from the Prescriber Block Queue.

g. If no action is taken regarding a specific claim, the claim will continue to remain blocked from processing at the pharmacy; however, the claim will not be removed from the Prescriber Block

Queue.

4. Approving Blocked Medications: In circumstances where a CCE/NPN determines a medication for a blocked prescriber should be allowed and 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.

1 Please note that the Program is working on updating the system so that approvals are only applicable to the specific drug or prescription, rather than applying to all medications in the member’s profile.

2 Drop down will be updated in version 2 of development for the portal. New drop downs will be - Denials: 1. Provider is deceased, 2. Not a WTC Health Program affiliated provider, 3. WTC Health Program affiliated provider, but drug is not WTC-related, 4. Other. Approvals: 1. WTC Health Program affiliated provider. Intend to enroll as prescriber. 2.Not a WTC Health Program affiliated provider. Do not intend to enroll as prescriber. Drug is WTC-related.

c. The following are the steps to override “Prescriber is Not Covered” blocks in the Prescriber Block

Queue (See Image Below):

i. Under PA Action: select “allow”

ii. Decision Driver: select the following –

1. Provider registered with WTC Health Program

iii. Effective Date: date the override should be effective from (could be todays date, retroactive date, or future date)

iv. Expiration Date: date the override should end

1. Limitations: up to 1 year3

v. Comments: document your rationale and the plans for enrolling the provider in the comments section of the Prescriber Block Queue.

5. 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 Express Scripts Client Service Center (CSC). CSC would update the members profile to ensure this individual prescriber will be blocked from future fills for that member.

6. Documentation: Notating the justification for the CCE’s/NPN’s decision in the comments section of the Prescriber Block Queue is a requirement for all overrides.

7. 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.

8. Samaritan Fill: If the prescriber block happens outside of normal business hours for the CCE/NPN and the prescription is urgent in nature and does not have any other blocks, the dispensing pharmacist may work with the Express Scripts Pharmacy Operations Team to obtain authorization for a short-term (3 days) “Samaritan fill” of a medication on formulary.

3 If intention to have the block or approval be indefinite, a date can be chosen far into the future.

WTC Health Program Provider Blocks Standard Operating Procedure

3. QUALITY CONTROLS

The PBM will report on Prescriber Blocks in their semi-annual reports, including the authorizations and denials, for auditing purposes. The CCE/NPN should carefully document rationale for decisions in the Prescriber Block Queue related to authorizing or denying prescriptions from providers that are not authorized prescribers.

The WTC Health Program will be able to request ad hoc reports for all decisions made in the

Prescriber Block Queue4. 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.

4. ACRONYMS AND DEFINITIONS

Instructions: This section contains a list of terms and their definitions for key acronyms, words, and phrases that are required to understand this guidance material.

Term Definition

Standard Operating Procedure (SOP)

An SOP is internal documentation that provides a detailed description of key activities and operations with agreed upon steps and specifications.

4 These reports will not be available in Trend Central. The Prescriber Block Tool does not currently have the ability to produce reports, but development is planned for that in the next update after go-live.

Unit Identifier The unit identifier is used in the introductory SOP table under the SOP Number field. The unit identifier is used to standardize SOP naming conventions (e.g., Medical Benefits and Certifications Unit=MBCU, Contract Management Unit=CBU, Member Services and Enrollments Unit= MSEU, Pharmacy Benefits Unit=PBU, Communications Unit=CU, Technology Solutions Unit=TSU, Administrative & Business Support Unit=ABSU, Program Integrity & Risk Management=PIRM, Research Planning & Care Integration=RPCI).

5. RELATED DOCUMENTS AND APPENDICES

For IT support or issues related to the Prescriber Block Queue please refer to the Point of Contact SOP.

6. RECORD OF CHANGE

Instructions: The table below serves as a record of change throughout the document lifecycle.

7. DOCUMENT APPROVAL

Instructions: This section is for authentication of SOP review and approval. While this section is optional, best practices are to prepare the final document as a PDF with digital signature(s) from Program leadership.

Unit Chief, [Insert Unit Identifier] Deputy Director

(or Deputy Director) (or Associate Administrator)

Version Number

Date Section Number

Description of Change

1.0 MM/DD/YYYY All Initial Publication

2.0 MM/DD/YYYY 2.0 List the change in bullet point format. Identify the changes that have given rise to a reissuance of this SOP, which could be:

● SOP was reviewed, but no changes made to content.

● Procedural amendments which are to be summarized.

● Policies that affect this SOP and may alter procedural contents.