Clinical Third-Party Call Handling (Pharmacies & Providers)

This guide outlines the mandatory protocols for handling inbound calls from external healthcare professionals, specifically Pharmacists and Medical Providers or Providers Offices.

When a third party calls regarding a Member’s prescription or Prior Authorization, there is a strict limit to what can be discussed. As an Agent, your primary role is to verify identity, collect data, and route the request. You are not authorized to make clinical decisions or disclose private health information (PHI) beyond the scope of this guide. Use the tables below to determine exactly who you can speak to and what information is safe to share. Do not change the requester on third party call profiles, instead create a new ticket for the member when you need to make direct contact.

Definitions: Who is a "Third Party"?

For the purpose of this workflow, a Third Party is any professional entity calling regarding a Member’s prescription or Prior Authorization. This typically includes:

Pharmacists / Pharmacy Technicians: Calling to adjust a script, check on a Prior Authorization (PA), or clarify dosage.
Medical Providers (Clinics/Doctors): Calling to check on a PA status or discuss a mutual patient.

Verification & Interaction Matrix

Mandatory Step: Before proceeding with any workflow, you must verify the caller and the member using the table below.

Caller Type

Step 1: Verify Caller Identity

Step 2: Verify Member Identity/ Medication Prescribed

Step 3: What Can Be Discussed?

Pharmacist

Pharmacist's Name
Pharmacy Location Name
Pharmacist's License State
Pharmacist's NCPDP number

Member's Full Name
Member's DOB
Medication and dosage
Prescribing Doctor (check if correct VMP)

(Lookup in HGP/B2B to confirm)

Rejection messages
Adjustment requests
Diagnosis codes

Advise pharmacist that a request will be escalated to the Prescribing Team and processed in 24-72 hours.

Medical Provider/ Providers Office

Caller Name
Clinic/Practice Name
Clinic Phone Number

Member Full Name
Member DOB

(Lookup in HGP/B2B to confirm)

Allowed: Ask the provider or office for information regarding PA requests or medical necessity.
Restricted: Do NOT provide specific approval/denial reasons or private health info.

The "Safe Approach." Tell the Dr's office:

"If a patient was told by the pharmacy that they need to enroll in Vida, they will need to set up an account with us directly. Some patients may be required to go through a Vida prescriber in order for the medication to be approved, depending on their plan requirements."

Critical Warning: If the Member is not found or not enrolled, you must NOT reveal their status. Simply state: "Please have the patient contact Vida directly."

General Principles & Constraints

When handling these calls, your primary goal is to Collect Data and Route.

DO NOT: Disclose private health information (PHI) or specific Plan details.
DO NOT: Provide a specific approval or denial reason (this must come from the clinical team/official correspondence).
ALWAYS: Check the Member's profile in HGP, B2B, or Admin to verify pertinent details (confirm if the prescription was sent, if the member's program is active, and check for any specific notes on the file/ in the chat) as well as identify if the prescription source is a Vida Medical Provider (VMP).

Specific Call Scenarios

Scenario A: PA Rejections

(Trigger: Pharmacy or Provider/ Provider's office calls because a claim failed/rejected)

Step 1: Collect Information for Internal Note

Capture the following exactly as stated by the caller:

Member's Full Name and DOB.
The exact rejection message provided by the Pharmacy/PBM.
The prescribed medication name.
Caller Details: Name of person, Name of Pharmacy/Office.
The Organization (Org) requirement regarding Vida enrollment (if mentioned).

Step 2: Check Enrollment & Take Action

(Do not change the requester on third party call profiles, instead create a new ticket for the member when you need to make direct contact. )

Member Status	Action Required
Needs to Enroll	Advise Caller: "The patient must contact Vida directly to proceed." System: Use "No Reply" macro → Mark Status: Solved.
Wrong Program	System: Create a new Zendesk (ZD) ticket → Contact the Member. Process: Once they respond, follow the Program Change Process.
Correct Program (but blocked by requirements)	System: Create a new ZD ticket → Contact the Member. Process: Once they respond, follow up with next steps Provide next steps depending on the outstanding requirement (e.g., Labs, Scheduling, or Forms).

Scenario B: Prior Authorization (PA) Requests

(Trigger: A provider or pharmacist calls stating a PA is required to fill a prescription)

Step 1: Collect Required Info

Medication name
Dosage
Date prescribed

Step 2: Identify Provider Source

Check HGP or Chat History to see who wrote the script.

If Non-Vida Provider:
- Action: Advise the third party that the Member must contact Vida directly. Use "No Reply" macro → Mark Status: Solved.
If Vida Medical Provider (VMP):
- Action: Proceed to Step 3.

Step 3: Escalation

Follow the Prescribing Escalation Flow to PSG Tier 1.

Scenario C: Prescription Adjustments

(Trigger: A pharmacist calls—or a member relays a pharmacist's request—to change a script, asks for diagnosis code, or scope of treatment)