List the guidelines for outpatient drug claims

Question

What will be an ideal response?

Answer 1

Answer:
a. A valid claim form must be on file showing the eligible diagnosis for which the drugs are being prescribed. This form shows that the patient was under the care of a physician for the covered diagnosis when the prescription was issued. After a valid claim form has been accepted, it is not necessary for a new claim form to accompany each drug claim as long as the patient is still under the doctor's care and the diagnosis is still valid. For example, if the diagnosis is of a chronic nature, drugs will often be refills of earlier prescriptions.
b. The pharmacy bill, receipt, or pharmacy statement for each prescription must accompany the request for payment.
c. All drug receipts or pharmacy bills must show the prescription number, the name of the physician, the name of the patient, the date of issuance, and the amount charged. If any of these items are omitted, the validity of the prescription should be checked prior to payment of the claim. Some receipts may also list the type of drug. This is helpful for determining whether the drug is a prescription drug or an over-the-counter drug.
d. The drugs must be appropriate for the condition being treated, the amount of time since the first diagnosis of the condition, and the amount of drug prescribed. For example, persons suffering from a serious heart disease or diabetes may require large amounts of drugs over an extended period of time, whereas a patient suffering from an ear infection would require a small amount of drugs over a much shorter period of time.
e. If prescriptions are questionable, further information should be obtained from the prescribing physician, not from the patient.