Audit Trap: OptumRx’s Provider Manual Requirements

PAAS National® is starting to see more recoupments from OptumRx for missing prescription information. These recoupments stem from the provider manual requirements for prescription documentation that includes:

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  • patient full name
  • patient address
  • patient date of birth
  • prescriber full name
  • prescriber address
  • prescriber telephone number
  • other required identifiers of the prescriber (NPI, DEA, etc.)

OptumRx is stating these items are required on all prescription documentation, regardless of the way it has been created, generated, or transmitted (e.g., telephone orders).

This section of the provider manual has rarely been enforced by OptumRx until very recently. When cited for missing elements, pharmacies are not provided a pathway to appeal, even though these items may not be required by state or federal regulations. Even pharmacies who have this information visible on backtags have struggled to get it accounted for. Independence Blue Cross has also been known to cite the OptumRx provider manual for missing prescription documentation.

OptumRx is not the only PBM that has this type of language in the provider manual. Both CVS/Caremark and Express Scripts have similar language, although PAAS has not seen these sections enforced. Since provider manuals are considered extensions of your contract with the PBM, they can enforcement the requirement, absent state law prohibitions and applicability.

PAAS Tips:

  • Get into the habit of creating good documentation for prescriptions, especially telephone orders and transfers that may be handwritten.
  • Familiarize staff with provider manual requirements for prescription documentation.
  • Check your state regulations for additional prescription documentation requirements.
Jenevra Azzopardi, CPhT