Mail Service Pharmacy (4.0) 4.0

OPS 4-2: Verifying Eligibility

Submited by: Tom Goddard

The Basics

This standard requires that the pharmacy's policies promote medication management that is cost-effective. This includes processes such as substituting generic medications and reducing or avoiding polypharmacy if clinically indicated.
In addition, this standard requires that the pharmacy confirm that each patient is within the pharmacy's scope and has benefit coverage. 
Finally, the pharmacy must have processes to explore financial assistance when appropriate.

Management Tips

This standard likely will be addressed with two distinct policies, or in distinct sections of a larger program description. The first section should lay out the full array of cost-conscious strategies to be utilized by the pharmacy. Remember, URAC requires policies to assign accountability for processes, so identify which members of the staff will be in charge of the implementation of such strategies.
The second policy or program description section will need to describe who will be conducting verification of eligibility for services and assistance and the methods that person will use to conduct that verification. Be specific and detailed as you craft this language.

Accreditation Tips

Desktop Review
Submitting the policies described above will suffice at this phase of the review process.
Validation Review
The reviewer will discuss both categories of activities (cost-savings and verification) with the appropriate members of the staff.

  • Health Utilization Management 7.4 / 04.01.2020

    HUM 41 - Appeal Record Documentation

    This standard sets for the minimum requirements for your appeals records:Patient nameName of provider and/or facility rendering serviceCopies of all patient correspondenceCopies of all provider/facility correspondenceActions taken and the dates they were taken, including decisions, correspondence, and resolutionMinutes from any appeal proceedingsThe name and credentials of the appeals reviewer for...

  • Health Utilization Management 7.4 / 04.01.2020

    HUM 40 - Written Notice of Upheld Non-Certifications

    This standard prescribes the minimum requirements for the written notice of an adverse appeal decision (one upholding the initial denial of the request for certification):It must be sent to the patient and ordering provider or facilityIt must state the principal reasons for the decisionIt must state that your organization will provide the clinical rationale underlying decision in response to a wri...

  • Health Utilization Management 7.4 / 04.01.2020

    HUM 39 - Standard Appeal Process Time Frame

    This standard requires that, in the case of a standard appeal, you send written notification of the decision within 30 calendar days of the receipt of the request for appeal. That notice needs to go to both the patient and the ordering provider or treating facility.