A Clinical Review is critical when a member is blocked, denied, or challenging a medical determination regarding their prescribing eligibility (including being not eligible for GLP-1). This guide outlines how to identify the need for a clinical review and the required escalation process via the Prescribing Support Group (PSG) Tier 1.
How to Identify a Clinical Review Need
A Clinical Review is required when the standard eligibility criteria or records are insufficient, complex, or disputed by the member.
The need for a clinical review is triggered by the following situations:
- The member explicitly disagrees with a recent medical determination made by a Vida provider or the enrollment team due to complex medical conditions/exclusions. Diabetes is an excluded condition for MWL; prescribing is unavailable if disclosed or found in claims history. Advise the member of this exclusion and use the GLP-1 diabetes denial macro.
- The member claims to have a qualifying condition that is not currently listed in their claims data or exclusions on file.
- The member is presenting complex or unclear clinical history that requires assessment beyond standard intake procedures.
Preparing the Member and Escalating to PSG Tier 1
After identifying the need for a clinical review, the agent must collect supporting documents from the member and initiate the formal escalation protocol.
A. Document Collection and Guidance
The review team will usually request documentation, and the member will need to be prepared to upload these documents to their app. To expedite the process, please inform them that the documents requested are usually the below listed, so they can upload them if they have them ready.
| Document Type | Purpose | Recommended Agent Scripting |
|---|---|---|
| Recent Lab Results | Confirms current metabolic, endocrine, or other objective markers. | "To give the team the clearest picture of your health, do you have any recent lab results that could be uploaded to your app?" |
| Medical Summaries | Validates the diagnosis and treatment plan from specialists. | "Could you please upload any medical office visits or ER summaries from your PCP or specialists (like oncology, GI, endocrinology, etc.)?" |
| Medical Letters | Provides explicit clearance or recommendation for program participation. | "Do you have any medical letters of recommendation for a telehealth program that you could upload to the app?" |
B. Prescribing Issue Escalation Protocol (Internal Ticket)
Use this protocol to escalate the issue to PSG Tier 1. PSG Tier 1 will triage the request (send to QA for review or reach back to the member directly).
| Step | Action Required | Details and Mandatory Fields |
|---|---|---|
| 1. Gather Unique Information | Collect the specific details required for the member's issue. | Refer to the " How to Identify a Clinical Review Need" section for necessary data points (e.g., specific challenge to the determination). |
| 2. Create Internal Note | Apply the macro and include all mandatory information gathered in the ticket's internal notes/body. |
Macro:Prescribing Support:: Prescribing Escalation Template macroMandatory Fields to Include: * Team Code: * Prescriber Name: * Member's pay-org: * Associated Program: * Member's state: * Context of the request: (State the specific issue: Clinical Review Request) |
| 3. Set Member Expectation | Inform the member of the next steps and estimated timeline. | Use the "Final Escalation Step" talking point (referencing the 30-day timeline below). |
| 4. Send Follow-Up Macro | Confirm the escalation and provide official notification to the member. | Send macro: "Support Ticket Escalated to Internal Prescribing Team" to the member. |
| 5. Final Submission | Assign and submit the ticket for triage in the internal system. | Assign the ticket to:PSG Tier 1.Set the ticket status to:Open. |
3. Timeline and Status Clarity
The Clinical Review process involves specialized internal review by the QA and Clinical teams. Agents must manage the member's expectations regarding the processing time.
| Topic | Guidance for Member | Internal Status Check |
|---|---|---|
| Processing Time | Maintain the 30-day window as the expected timeframe for a decision. Advise the member that the complexity of the review and current ticket volume require this duration. | PSG Tier 1 manages the status. Advise the member that due to backlog, the 30-day window remains the expected timeframe. |
| Status Update | Advise the member that a final decision will be communicated to them directly (usually via email from the prescribing support group or qavida@vida.com). |
Check Internal Notes on the ZD Ticket: QA leaves notes when member requests or documents have been reviewed and will update the member directly. |
| Determination/Process | The detailed clinical rationale for the final determination or the internal process itself is not shared by the support team. A decision (approval or denial) will be communicated by the appropriate team member. | The specific details of the clinical determination are handled by the QA and Clinical teams and should not be disclosed to the member by member services agents. |
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