If the agent cannot answer for “Does the specialist office copay apply regardless” and the admin code and specialist office visit copays are same an escalation is, Required with a supervisor, Required to PA dept, Mark Yes and no escalation is needed, If the agent cannot answer PA requirements we escalate to PA dept, True, False, If the agent answers there is a medical group that handles the PA, Skip all the PA questions as well as referral questions and continue, Disconnect the call immediately and escalate to medical group, Continue and ask all PA questions, If the agent asks us to contact PA dept for PA on file skip all the other questions, True, False, If there is an approved PA on file and agent mentions PA is not required and PIE turns red, Escalate to PA Dept, Disregard the agent’s answer and keep PIE red, We need to escalate to PA dept if the agent cannot answer “How do you coordinate benefits with the primary insurance?”, True, False, If the agent mentions plan is secondary to Medicare Part A and B and PA is required, No need to escalate as secondary plans does not require PA, Escalate to PA dept, If Buy and Bill is PIE locked and agent’s answer conflicts with PIE, Escalate to PA, Escalate to supervisor, If the agent cannot answer both Buy and Bill and Specialty Pharmacy Info even after PB, HS, Escalate to PA, Escalate to supervisor, For PBV scenarios if agent answer conflict with PBV escalation is required, True, False.

Escalation

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