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Clinical, Provider & Pharmacy Escalations

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Axel Mora
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Overview: Use this guide to properly route inquiries to the Prescribing Support Group and Clinical Team. This article covers workflows for:

  • Resolving prescribing escalations, pharmacy issues, and lab work.

  • Navigating provider changes and switches.

  • Handling member complaints, feedback, clinical disputes, and requests for clinical review.

  • Urgency Protocols: Do not escalate anything as urgent unless it involves severe side effects or a Red-Level medication (Topamax/Zonisamide, Contrave/Bupropion/Naltrexone, and all Condition Control Program medications).

 


 

1. Provider Switching & Routing

⚠️ CRITICAL CHECK FIRST: Look in Admin > Programs. Does it say "Suspended Program Dash Coordinator"?

  • YES: Escalate to #QA-CS-Therapy-support via Slack Side Conversation.  If it is not an issue of member needing to meet with CN (Clinical Nutritionist) then escalate via JIRA

  • NO: Proceed with the chart below:

Provider Type Action & Routing Path
Coach or RD

1. Try App/HGP Switch first.


 

2. If app fails > escalate to Tier 2 


 

3. Tier 2 will complete request using instructions here
Prescriber (VMP) First try switch feature on HGP, if you encounter issues, Route to PSG. Use macro Prescribing Escalation Template. Assign to Prescribing Support Group (PSG Tier 1).
VMP (Moving Out of State) Escalate to ProdOps via JIRA [System] Service Request.
Therapist / Mental Health Escalate to #QA-CS-Therapy-support via Slack Side-Convo.
Specific Provider Request Escalate to ProdOps via JIRA [System] Service Request.

2. Pharmacy, Prescriptions & Labs

Issue Type Action & Routing Path
General Pharmacy Issue

Fill Prescribing Escalation Template > assign to PSG Tier 1.


 

🚨 Mark Urgent if  it is a red medication member is at the pharmacy, experiencing side effects, or if escalated by an Account Manager. 
Dosage / Instruction Qs 🛑 STOP. Do not interpret scripts. Confirm member info & pharmacy contact, then escalate IMMEDIATELY to PSG Tier 1 using Prescribing Escalation Template .
Prescription Refills Follow the Prescription Refill Requests KB.
VMP Prescription Denied at Pharmacy

Review the timeline: Check the date of the member's last consult.

Verify the prescription: Check the Admin under programs> program instances> click into the AMS program portal and check the chat history to confirm that the assigned Vida Medical Provider (VMP) sent the prescription to the pharmacy.

Escalate: If everything looks correct, but the member states the prescription is still being denied because it needs a Prior Authorization (PA), escalate the issue to PSG Tier 1 using Prescribing Escalation Template 
Zepbound Exception Request

  • Action: Run the macro Prescribing support > Escalation > Exception request.

  • The macro will guide you through the following workflow:

  • Step 1 (Input): The macro prompts you to fill out the PSG Escalation Template.

  • Step 2 (Reply): It automatically generates the member reply using the Wegovy/Zepbound Exception Request verbiage.

  • Step 3 (Routing): It triggers the Internal Prescribing Team escalation logic, assigning the ticket to PSG with a status of OPEN.

    Follow CVS Caremark Zepbound Exception Requests to ensure eligibility for the member. If eligibility is not confirmed only complete step 1 of the process, PSG will follow up with the member directly for step 2. 
Wegovy Exception Request Escalate to PSG using the prescribing escalation template macro advise the member that the prescribing support group will reach out to them directly within 24-72 hours with next steps.
Provider Complaints Offer a provider switch first. If they insist on a formal complaint, fill out Provider Complaint Escalation Template > assign to PSG Tier 1.
Lab Orders

If member needs labs sooner than scheduled or is stuck at the lab >Escalate to Documents Processing team ( Manual Ops) via JIRA [System] Service Request.

If the member is at the physically at the lab and needs assistance with a lab order please escalate using the standard JIRA escalation process for labs, then message Jennie Le on slack for urgency.
Lab Review Escalations JIRA Escalation for VMP Scheduling Blocks & Missing Lab Errors
Medical Records Follow the Sending Members Their Data KB.

3. Clinical Disputes 

Use this workflow when a member claims clinical eligibility or disagrees with a clinical decision or program discharge.

Phase 1: Verification Steps

You must investigate the member's status before routing the ticket.

  1. Check Status: Go to AMS: Admin > Program Instances check the program labeled AMS ( Advanced medical services ). (Note: If the State says "Complete," they have been officially discharged or placed in behavior pathway if MWL is active - do not use the term 'discharged' with members).

  2. Find the Reason: Check the Provider Chat history to locate the specific off-boarding message. 

  3. Route It: Based on the reason found in Step 2, use the routing matrix below.

Phase 2: Escalation Routing

| If the Discharge Reason is... | Take this Action |

| Unknown (Cannot find reason in chat) | Escalate directly PSG by filling out PSG escalation template. |

| MWL Behavior Pathway | Use the macro: Prescribing Support::Behavior Pathway. |

| Self-Submission / Member Dispute | Ask the member to email qavida@vida.com AND use the macro: QA::Member Grievance - Request Clinical Review. |

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