Calling a prescriber’s office due to a prescription with missing elements, or needing clarification, is an inescapable task.
If you are failing to document that phone call with a valid clinical note, PBMs may flag the claim upon audit and try to recoup.
We have seen OptumRx, Humana, Navitus, and ESI/Prime results citing pharmacy clinical notes. Many of the provider manuals have language on what a valid clinical note should minimally contain.
Our experience upon reviewing audit documents, results, and provider manuals is that a clinical note should contain four elements. If the following elements for a clinical note are present, they will reduce an auditor’s ability to recoup upon audit.
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