Prescriber Statements for Successful Appeal

One of the most common requirements for appealing audit discrepancies is to provide a signed statement from the prescriber to confirm, clarify, or validate a prescription. Prescriber statements that do not meet all PBM requirements may be denied on appeal.

Pharmacies are often confused by what or why these statements are necessary and often find it very difficult to obtain a statement that meets all the requirements. PAAS National® analysts have years of experience with prescriber statements and are happy to walk you through this process for the best possible outcome on your appeal.

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Humana currently includes a prescriber statement template with their audit results. While this template does make obtaining a complete statement from the prescriber much easier, this form does not meet the requirements of other PBMs.

Prescriber statements are often denied when pharmacies create the statement for the prescriber. It is imperative you provide the prescriber with the detailed information needed; however, the statement itself must be created by the prescriber, or prescriber’s office.

Elements missing from a statement can be another reason for denial. Here is a list of the most common requirements, but be sure to check with your PAAS analyst for specific PBM nuances:

  • Statement should be on office letterhead of the prescriber
  • Origin of the statement if no letterhead is available (e.g., visible fax header with prescriber information or prescriber office stamp)
  • Have all elements of the original prescription, but be in statement form
    • Prescriber full name, address and phone number
    • DEA number and patient address if medication is a controlled substance
    • Patient name and date of birth
    • Written date of prescription
    • Medication name and strength
    • Quantity and refills prescribed
    • DAW if applicable
    • Any additional information needed to clarify discrepancy flagged
    • Prescriber’s handwritten signature (electronic and stamped signatures are not accepted)
    • Date the statement was written/signed
  • Pharmacy can add prescription number to the bottom of the statement for auditor reference

Have audit results and need assistance with appeal? Contact PAAS National®® today for one-on-one assistance with an experienced analyst.

Dana Westberg, CPhT