The right way to deal with a problem with Express Scripts
July 15th, 2010 | TriCare Help | Posted by Military Times
Q. Why is Express Scripts such a frustrating outfit to do business with? They have not responded to two greivance letters. In particular, I do not believe that they have paid out one single dollar for paper-processed claims for reimbursement that I have filed on behalf of my mother. They just recycle the paperwork back to you and they don’t care.
Your communication problems may have to do with the Privacy Act. By federal law, Tricare, Express Scripts, etc. cannot discuss your mother’s claims with a third party (you) without her written consent.
As that is only a guess, however, please send a detailed report of your mother’s problem to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, Co 80011-9043. Both you and your mother should sign the letter. That way, you can be included in the communications loop. If your mother is unable to sign the letter, please include a statement to that effect.
Include copies of all correspondence and other pertinent documents and a telephone number where you can be reached during the day. Be sure to include your mother’s full name, her military sponsor’s full name, and his Social Security number.
The more information you provide, the more effectively you can be helped. As an example, your letter, above, provided no information I could have used to suggest things you might do to resolve the problem. Surely Express Scripts reported its reasons for not paying the claims. Or perhaps, they didn’t, and said they couldn’t discuss the problem with you because of the Privacy Act. I don’t know, of course.
TMA, above, is a federal agency and the worldwide Tricare Headquarters. That office has the authority to order copies of all your mother’s claims documents and analyze them to get to the root of the problem.
If your mother is enrolled in Medicare Part D Pharmacy Plan (which she does not need unless her income is below the federal poverty line), her problem may be related to the coordination of benefits between two pharmacy benefit plans. Such claims must be filed in a certain order and contain certain documents to be processed and paid smoothly.
Without Part D, all your mother’s prescription services can be handled locally by an Express Scripts network pharmacy, or by mail order where she can get a 90-day supply of her medicines at the same price she pays for a 30-day supply purchased locally. Find information about that on Tricare’s website.
Tags: appeal, claims, Medicare, other health insurance, pharmacy, secondary insurance
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