SWARM - Vendor Site Specialized Checklist - Revised

Checklist of questions while observing the new CD Process


CD Specialized Team Location
Madison
Raleigh


CCR First Name


CCR Last Name


CCR UID/ZID


Date/Time of call (mm/dd HH:MM)


Location of CCR Transferring call
Henderson
Houston
Madison
Raleigh
Fort Pierce
Sunrise
Yuma
Nashville
Nashville WFH
Orlando WFH
Solon
Solon WFH


Client Code


Drug Name


Drug Strength


Drug Dosage


Call Type
Tiering
Non-Formuliary
PA request
Other


IF PA/QL/Step Therapy
Did the CD Specialized Team Rep process an error for the CCRs misdirect by notifying their Supervisor with the CCR info?
Yes
No
N/A


Validate medication is Formulary or Non-Formulary?
Yes
No
N/A


Non-Formulary Request:
Did CD Specialized Team CCR Check for alts?
Yes
No


Non-Formulary Request:
Were alternatives available?
Yes
No


Non-Formulary Request:
If alternatives were available, did the CD Specialized Team CCR advise caller to contact MDO to discuss options?
Yes
No


Non-Formulary Request:
If member was advised, did member request an exception OR did not accept the alternative response?
Yes
No


Non-Formulary Request:
If yes, was the call appropriately transferred to CD&A at 1-855-240-0542?
Yes
No


Non-Formulary Request:
If no alternatives were available, did the CD Specialized Team CCR offer formulary exception?
Yes
No


Non-Formulary Request:
Did the member accept the Formulary Exception?
Yes
No


Non-Formulary Request:
If yes, was the call appropriately transferred to CD&A at 1-855-240-0542?
Yes
No


Formulary / Tier Request:
Did the CCR Validate the Tier the medication falls in?
Tier 1
Specialty
Tiers 2-4


Tier 1 Formulary:
Did the CCR advise member of Tier 1?
Yes
No


Tier 1 Formulary:
Was the member satisfied with the response?
Yes
No


Tier 1 Formulary:
If not satisfied with the response, did the CCR repeat the information a second time?
Yes
No


Tier 1 Formulary:
If the member is still not satisfied after twice advising them of being in Tier 1, did the CCR transfer to the CD Specialized Team?
Yes
No


Tier 1 Formulary:
Did the CD Specialized Team file a grievance if the member was still not satisfied after advising them twice of Tier 1 and no other options?
Yes
No


Tier 2-4 Formulary:
Did the CD Specialized Team CCR check for alternatives?
Yes
No


Tier 2-4 Formulary:
If alternatives were available, did the CCR advise to contact MDO to discuss alternatives?
Yes
No


Tier 2-4 Formulary:
If no alternatives available, did the CD Specialized Team CCR advise to contact MDO to discuss other options?
Yes
No


Tier 2-4 Formulary:
Does the member request an exception OR did not accept the alternative responses?
Yes
No


Tier 2-4 Formulary:
If yes, was the call appropriately transferred to CD&A at 1-855-240-0542?
Yes
No


Tier 5:
Did the CCR warm transfer to the Specialty Team at 1-800-237-2767?
Yes
No


Did the CD Specialized Team CCR process an error for the CCRs misdirect by notifying their Supervisor with the CCR info?
Yes
No


Documentation:
Did the CCR completely document the caller's request and outcome in their NOTEs for audit purposes (including supporting details, capturing the 5 W's - Who, What, When, Where, and Why)?
Documentation should be entered into the View Activity Comments Screen.
Yes
No


Please provide additional comments or coaching.





Guy Macdonald