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Determination - UC 14: Review and research Prescription Drug determination case

Updated on January 31, 2022
Pega Foundation for Healthcare
  1. Retrieve the case from Research workbasket.

  2. Review following information:
    • Determination Category
    • Determination Reason
    • Service Type
    • Place of service
    • Service date
    • Description (comments entered for Complaint reason while creating complaint)
    • True organization received date (Date on which Payer received the complete complaint details. SLA and deadlines are calculated with this date as a baseline).

  3. Edit urgency if required. If “Handled with urgency “is selected as “Yes” then case is handled with expedited urgency. System also updates the deadline of case based on urgency. For determination, if urgency is standard or urgent then deadline is set as 14 days/ 72 hours from “True Organization receipt Date”. Click Submit to move to next screen.
  4. Enter policy and guidelines details. User can enter multiple guidelines and policy information.
  5. User clicks Submit to move case to Prescription drug information screen.

  6. Click on ‘Attach content’ to attach files for the supporting documents and select the category as ‘Supporting documents’ while uploading the file.
  7. User clicks Submit to move case to next stage.
  8. System moves the case to MDReview@MyHealthplan workbasket.
  9. Refer UC13 for MD Review and UC8 for determination resolution communication.
  • Previous topic Determination - UC 13: Medical review of determination
  • Next topic Common - UC 15: Access case details/progress

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