The Medco Client Website – Member Services

Coverage Inquiries, Reviews, Appeals Quick Reference Card

The Coverage Inquiries, Reviews, and Appeals capability Viewing Case status, and criteria
Coverage inquiries, reviews and appeals (Coverage Management) is an The Case Search Results page returns case information corresponding to
automated system to monitor and manage the coverage review and/or the last activity only.
appeals process. It provides real-time access to coverage-related information
useful in making appeals and/or coverage decisions and resolve member Viewing case activity detail
inquiries. This capability helps: The Case Activity Detail page provides a detailed log of the most recent
• Support administration of coverage programs that can reduce activity with the option to view previous activities related to the case. There
drug trend are three types of case activities; Primary, Renewal, and Appeal.
• Provide real-time access to case information and snap-shots of ¾ To view Case Activity Detail
activity 1. Click on the “Last Activity”
• Service members faster and easier 2. Click on the ”Type” in the Activity Data to view the corresponding
• Support regulatory compliance detailed log.

Accessing the coverage management capability Viewing case communications history

The Communications History lists the communications relevant to a particular
The Coverage Inquiries, Reviews, and Appeals Applet (the middle portion of
activity within a case. This can serve as an audit trail to validate the amount
the Member Services screen) provides Case Search options to access this
of time that was actually taken to complete the case activity.
information and Coverage Activity Summary, if activated.
¾ To view Case Communications History
¾ To access the Coverage Management workstation
Click on “Communications” located on the left-hand side Functions menu
Click on the Member Services tab on the top of the Client Website
Welcome Page
A Case Search can be performed by entering a specific Case ID Number or Viewing reasons for denial
the member’s ID Number. The Denial Reasons page contains only those activities resulting in a
coverage denial. This information is valuable when making an appeal
decision. The general denial reason provides the clinical user with the benefit
User privileges conditions that were not met, but which are required to approve coverage. In
Case Information will vary based on user role privileges
addition, if the clinical user is speaking to the physician concerning the
• A “Non-Clinical” user will only have access to Case Search Results, appeal request, the actual denial reason that was printed on the physician’s
Case Activity Detail, and Case Communications History. letter can be seen.
• A “Clinical” user will have additional access to Reasons for Denial,
Coverage Criteria, Coverage Summary, and Case Activity Summary. Please note this will only be available for activities resulting in a denied
• The “Select/display Coverage Activity Summary” flag may be turned status.
on for either user.
¾ To view reasons for denial
Click on either ”Denied” Status in the Activity Data or “Denial Reasons”
located on the left-hand side Functions menu.

© 2001, Medco Health Solutions, Inc. All Rights Reserved.

(v 08/28/02)
The Medco Client Website – Member Services
Coverage Inquiries, Reviews, Appeals Quick Reference Card
Viewing coverage criteria Using the coverage activity summary
The Coverage Criteria page displays questions and answers of the Primary The Coverage Activity page provides the option of selecting one weekly
or Renewal review that resulted in a coverage denial. This information can be snapshot or one of seven daily snapshots of all related coverage review
helpful in making an appeal decision. activity. The data is compiled and may be viewed at either the contract or
¾ To view Coverage Criteria carrier level.
Click on the “Coverage Criteria” located on the left-hand side Functions Once a Coverage Activity view is selected, a summary is displayed providing
menu. the total number of approved and denied reviews for Primary, Renewal, and
Appeal activity types for the specified timeframe. The data will be grouped at
the product level (i.e. MPA, MRxC, QPC, Closed Formulary, and Co-payment
Viewing additional information Review). The individual drug categories will only be listed for MPA and
This information can include dosing information or a listing of references
MRxC.
used to develop the criteria. This information is reviewed and updated, if
needed, on an annual basis. ¾ To select or display the Coverage Activity Summary
Click on the “Coverage Summary” located on the left-hand side
¾ To view Additional Information (Citations)
Functions menu.
This feature is only available at the question level or at the end of the
“Coverage Criteria”.
Future development
Coverage Management is being enhanced to provide additional capabilities.
Viewing coverage summary When completed, the full functionality will offer users the capability to;
The Coverage Summary provides the user with details pertaining to the
• Integrate with e-SD; Eligibility and Claims
development of coverage criteria. This page lists the drugs included, what
they are and how they work, and the rationale and criteria that must be met • Administer appeals and generate correspondence
for authorization. • Administer coverage reviews and generate correspondence
• Track and/or manage contacts with members, physicians, and
¾ To view Coverage Summary pharmacists
Click on the “Coverage Summary” located on the left-hand side • Create and/or maintain coverage criteria
Functions menu.

Viewing the case study activity summary

The Case Activity Summary provides a comprehensive record of the case
activity that can be printed out and placed in the patient’s file.
¾ To view Case Activity Summary
Click on the “Activity Summary” located on the left-hand side Functions
menu.

© 2001, Medco Health Solutions, Inc. All Rights Reserved.

(v 08/28/02)