SCRIPTING FOR CASE MANAGERS



SCRIPTING FOR CASE MANAGERS-regarding Prior Auth Still Pending on Day of Discharge

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Talking to a physician about a Prior Authorization Pending on the day of Discharge:

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Confirm/update contact information of caregiver & PCP

• Hello Dr. ---------I would like to inform you that I have spoken with the caregiver-------- (mother/father/parent/legal guardian) Mr/Mrs/Miss ----------who will be contacted at #-----------.

• I was given the name and contact number for the PCP Dr. -------------, #-------.

• I will documented my conversation with you, and my conversation with care giver confirming the PCP in my Case Management Cerner note.

Inform caregiver that PA results will be updated once received

• Good morning, my name is____________ and I am the Nurse Case Manager- from Nicklaus Children’s Hospital.

• Dr. ---------- has indicated he/she would like – Patient Name ---------to go home with Name of Medication/s --------/------------.

• My role is to help you with obtaining prior authorization for the following medication/s ------------, ------------- as quickly as is possible so you can have the medications at home.

• Our hospital pharmacy will give you a 3 day supply of medications while I work with the pharmacy to get the full supply.

• According to the pharmacy benefits, this medication requires a prior authorization, which may take up to a few days to obtain.

• As the Nurse Case Manager, I am here to answer questions and help you obtain prior authorization for the discharge home, and you can call me at #--------------.

• Once I have received the prior authorization for the medications/ -----, -----, I will contact you on the same day, at the number you provided #----------------.

Explain future course of plan that will be followed based on PA approval decision.

• During my conversation with the approving pharmacy, they will tell me about any special instructions or additional steps to take.

• In order to have the medications without delays, you and I must follow the instructions and requirements based on the type of drug and your pharmacy benefits.

• It may be that you need to pick up the medications at your regular pharmacy, or that I need to fax the prescription/s and authorization number to a special pharmacy after the prior authorization

• The pharmacy might tell me that the medications will be mailed to you- and they will tell me the date you will receive. Or it may be that you have to pick it up the medication/s at our hospital’s outpatient pharmacy.

Explain that future course for plan will be updated through calling the next 48 hours if PA approval result is not obtained

• After you are discharged with 3 days supply of medications, I will continue to call the pharmacy to obtain prior authorization, at least twice during my shift. Or if I am off, another Nurse Case Manager will call the pharmacy

• During the first day after your discharge, I or another Nurse Case Manager will contact the pharmacy, and then contact you to let you know of the outcome, whether an approval is obtained or not.

• I or another Nurse Case Manager will also contact Dr. --------the hospital discharging physician - to let him/her know about the result whether prior approval is obtained or not.

• Prior to discharge, the Case Management Director, Philicity Tinnie-Wilson, RN will be informed of the discharge plan to discharge home with 3 days of medications, pending prior authorization. (This conversation will occur prior to discharge, on discharge day, and ( escalated ) each day after discharge until approval or alternative plan is established; so as not to incur a readmission due to lack of prior authorization).

• I will or another Case Manager will document in the Case Manager note the prior authorization obtained – including the number – as well as if no prior approval is not obtained.

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