2014 Payer Advocacy Success Case 3

 

The GIRS Payer Advocacy Compass (PAC)™ Team worked with a state Medicaid program to advocate for the Medicaid coverage of two biologics. Our ongoing professional relationship with the Medical Consultant of this plan allowed GIRS to obtain information on what products are coverable, along with the protocol for non-coverage and unknown products.  GIRS was able to determine that one of the products would be covered, as long as supporting documents were sent WITH the claim, which would then be reviewed and covered if found medically necessary. The second product was determined to be a non-covered Product.  GIRS was able to obtain the necessary information to have a non-covered product be reviewed by the payer’s Medical Review team, including a direct address to send the clinical information.  We are currently working with the payer to ensure that the medical policy review is completed and that the payer needs for data are met.