2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Pharmacyimmediately communicated to the requester byphone or fax and are entered into the system.If the request does not meet the approval criteria,the request is immediately routed to the clinicalpharmacist, who approves the request if justified. Ifnot, the request is routed to the medical director fora determination. If the request is denied, notificationis given to the requester by phone, includingnotification of the availability of the medical directorto discuss the case by phone, and of the right toappeal the decision. A written notice of thepharmacy decision (approved or denied) is alsoissued to the member with a copy sent to theprovider.Appeals ProcessAn appeal may be submitted orally or in writing if amember is not satisfied with the decision to deny apharmacy prior authorization request. The providermay submit an appeal for members with themember’s consent.8-132014 Practitioner and Provider Manual - Ver. 3