CMM Confluence Review

If GPI list description includes NONCLNCL or DACON we would search for:

• NONCLNCL Criteria set

• Any Criteria set

• Our specific program criteria set

• General QL

Answer explanation

WY doesn't review for:

• Netresults Member

• 70 reject for NetResults account

• 70 reject for Commercial account

• Standard Commercial

Answer explanation

We would select _________ question set for Reject 70 RXEX: Use (preferred drug name)

• Coverage Exception Criteria set

• Coverage Exception for ED meds

• Drug Exclusion with Alternatives

• Exception Criteria Closed benefit with ACA

Answer explanation

If NJ rejects for 75 and GPI list contains ST/QL our program type would be ?

• Prior Authorization

• Step Therapy

• Smart PA

• No Review Needed

Answer explanation

We route to Pharmacist if :

• Question set is incomplete

• Outcome reasons have a denial point

• Validation point labeled "Miscellaneous" in the Outcome reasons

• There's a High Touch indicator

Answer explanation

When routing to closure we set Recommended Outcome to ______ and All Review info Received to ____

Answer explanation

KS only review for _____ CE cases

We not merge Additional Information cases to :

• Canceled Cases

• Merged Cases

• Approved Cases

• Non-reviewable Cases

If merging to a CE met/UM denied we would review for :

• CE/UM and Program type CE

• CE only Program type CE

• UM only Program type CE

• CE/PA Program type CE

Answer explanation

NJ, WY and Cambia does not require Sexual Dysfunction BET note

• True

• False