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Guide to Working With Express Scripts for Claims Processing

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One of the giants of the American medical claims processing industry is Express Scripts. This 100 billion dollar company is responsible for pharmaceutical claims processing and disbursement for millions of Americans. It has programs that handle the provision of medicines for a large number of notable customers, including corporate clients and the U.S. federal government.

Express Scripts has come up with innovative methods of medical prescriptions delivery that include mail delivery and online filing. The ability to access claims online and submit forms over the internet speeds up the process for patients that need to get medicines.

The company runs a central website where patients can submit paperwork. In addition to its own sites, partners like the TRICARE program run their own sites and resource networks that integrate with Express Scripts. With the TRICARE Pharmacy Home Delivery program, for example, patients can receive medications right at home without visiting a pharmacy.

Express Scripts Prior Authorization

While many medications can be purchased over the counter or with a normal prescription, some medications are restricted. For such medicines, the patient will need to go through the prior authorization process (PA) in order to get the medicine.

There are guidelines that specify when prior authorization is required. Generally, this falls into a few scenarios, such as:

• A high dose that exceeds normal levels for the drug
• If the drug is potentially dangerous and has been identified as such by the Pharmacy and Therapeutics Committee of the DoD
• If there are age restrictions on the usage of the drug

To begin the prior approval process, you must find the drug online using the TRICARE Formulary Search Tool. You will then need to give your medical doctor or pharmacist the form for the medicine. After completing the form, the provider has to mail it in to Express Scripts so that you can get prior approval to receive shipments of the drug.

Filling in PA Forms

A prescriber can use various platforms such as Cover My Meds in order to find the Express Scripts PA forms. There are different forms depending on the state that the doctor or pharmacist is located in. The form requires the personal information of the patient for whom the authorization is requested. In addition, the doctor or registered pharmacist must fill in their medical practitioner information.

Other information required on the Express Scripts PA form includes:

• Reason for requesting the special medicine, if a generic medicine exists
• Other medications that the patient has been taking
• The diagnosis of the patient's medical condition
• DEA/NPI number for the prescriber
• The phone number and medical office information of the prescriber

How the Approval Process Works

It is also possible to initiate the prior authorization process over the phone as opposed to on the internet. In that case, you should have your doctor call Express Scripts toll-free at 800-417-8164. There's also the alternative to send in a fax to 800-357-9577. Besides getting medicines delivered to your door with Express Scripts, you also have the option, often, of picking up medicines at a participating local pharmacy.

Sometimes, a request is rejected by Express Scripts. While you may be able to put in an appeal, if that is not successful, you will have to pay for the medications yourself. In addition, you might have to submit an authorization request each year or at other regular intervals. This is necessary to receive the necessary prior authorization for medicines that are deemed unsafe for general traffic.

Using Express Scripts Online

Keeping track of the exact procedures for your program can be hard to do. This is because many organizations, public and private, have different policies that apply to working with Express Scripts. For example, at the federal level, Express Scripts provides pharmaceutical disbursements for Medicare recipients.

Each program will allow for the coverage of certain medicines, and will not provide coverage for others. The forms you need to fill will be different based on your company or organization's medical benefits package.

Getting all the information and forms that patients need can be hard to do on paper. Fortunately, a patient can sign in with Express Scripts online in order to easily conduct most transactions.

With an Express Scripts online registration, you can:

• order delivery of medicines via mail
• check the progress of orders you have placed for medicines
• place orders to receive meds refills

Subscribing to Express Scripts online is a good step for reducing the amount of errors that occur in filling orders. Online, things are easier to track and you can verify all your information in your account in one central location.

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Source: https://www.life123.com/article/guide-to-working-with-express-scripts-for-claims-processing?utm_content=params%3Ao%3D740009%26ad%3DdirN%26qo%3DserpIndex

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