QualityCheck Updated 07

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Colorado Christian University *

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103A

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Medicine

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Apr 3, 2024

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docx

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1) Services Requested: 1. Confirm at least one service is selected. If none are selected, this is missing information. 2) Treatment  Related Brand/Clinical Data: 1. Confirm that the drug added under Related Brand, matches the drug selected on the enrollment form. a. If Data Intake adds the wrong brand, cancel out any pending cases under the wrong brand, add the correct related brand and create a new BV case under the correct related brand. i. To create a new related brand, hover over related brand hyperlink in Person Account and hit “ New Related Brand ”. (Remember to add Related People and clinical information before creating any new cases) 2. Diagnosis code: a. Confirm that the diagnosis code is valid and billable by using www.icd10data.com b. Confirm that the diagnosis code and description match. c. Confirm the diagnosis code was added to the clinical data under the person account and related brand. d. Always assume a dx is on-label unless the site clearly states a reason that would make it off label (first line, MSI-Low/Stable, SCLC, etc.) If the site indicates the dx is off-label, but appears on label, call the site to confirm why dx is off-label. i. None listed for previous therapy doesn’t mean first line, still assume this is on label until the site confirms verbally. ii. Update the Concomitant Field on the Person Account on the clinical data tab for all Medications that will be given in combination with our BMS product . Some examples listed below: 1. If EF or site states Opdivo is in combination with another drug, enter that drug’s name in the field (Medications that treat the patient’s cancer). 2. If EF or site states, the patient has NSCLC with no line of therapy a. NSCLC - Unknown 3. If EF or site states, the patient has SCLC with no line of therapy a. SCLC - Unknown 4. If EF or sit states, the patient has NSCLC or SCLC + line of therapy a. NSCLC or SCLC – First Line b. NSCLC or SCLC – Second Line c. NSCLC or SCLC – Third Line d. NSCLC or SCLC – Fourth Line e. NSCLC or SCLC – Not First Line e. If the dx is an unspecified secondary dx this will be considered MI to see if the site has a more specific diagnosis code. (example: C79.9 = Secondary malignant neoplasm of unspecified site).

i. If the dx is specific enough, we can use this as a primary dx (example: C79.2 = Secondary malignant neoplasm of skin) f. Is there something included in the description that makes it off label? i. If so, make sure to include this in the Escalation Notes g. Is histology included: i. If so, include this in the Escalation Notes 3. Does the monotherapy/in combination box match with the treatment as provided: a. If monotherapy is checked but another drug is provided this is missing information b. If combo-therapy is checked and no other drug is provided it is missing information, except for Opdivo+Yervoy. i. If the dx is for lung cancer for Opdivo + Yervoy confirm if the patient’s histology is SCLC or NSCLC. ii. If the patient is uninsured, no follow up is necessary since the patient has no coverage. c. What type of drug is the BMS product being used in combination with? i. Another chemotherapy agent besides what the FDA approvals are for: Off-Label ii. A support medication such as Xgeva: would not affect the on versus off-label status d. For Empliciti: i. Did the site provide what Empliciti will be used in combination with, we will need to confirm if the site is using both Dexamethasone with FDA approved pomalidomide (Pomalyst), lenalidomide (Revlimid), or NCCN indicated Velcade (bortezomib) ii. If this information is not provided the file goes in missing information iii. If the patient is uninsured, no follow up is necessary since the patient has no coverage. 4. Confirm the therapy provided in box is checked: (Specialist office or Hospital Outpatient Setting) a. If this is a new site, the file will go in missing information. b. If this site has used our program before i. Check the site notes on the Team Page. ii. Check previous enrollment forms. iii. If neither have this information the file goes in missing information. 5. Did the site provide the dosing: i. For infusion drugs we can proceed without dosage as we will assume the MD will treat the patient according to FDA approval. However, the dosage is needed for oral products. ii. If Opdivo does not list the dosage, assume the patient will be treated at 240 mg q 2 wks. Only input 480 mg q 4 wks if listed on the EF or with treatment notes. 3) Physician Information Page  Related Brand  Related People: 1. Confirm the physician’s name matches the one in the system. 2. Confirm that we have the individual NPI for the physician.

a. This can be confirmed on https://npiregistry.cms.hhs.gov/registry/ 3. Confirm that we have the tax id on file. a. If not in the site notes or on a previous enrollment form the file will need to go into missing information. 4. Confirm the facility name matches the one in the Fusion. 5. Confirm the address for the facility matches the one in the Fusion. a. Important note: Some sites may have multiple addresses on file due to having a claims department at a different location. Make sure the address on the Enrollment form matches the correspondence and shipping address for the site added to the Fusion. b. Make sure to search multiple ways before adding a new site. 6. Confirm the Related People have the correct Provider Site Relationship added. a. There should be 2 Provider Site Relationships with the same Provider and Site. i. Treating/Shipping Provider ii. Treating/Correspondence Provider 7. Is the providers signature present on the enrollment form? a. The provider who signed the enrollment form must be the providers who name and NPI appears at the top of the enrollment form. b. If the signature is present, update the Consents/Opts/Preferences tab with the following information: i. Provider Auth on File? Yes ii. Provider Auth Received Date: Date from document cabinet iii. Provider Auth Signed Date: Date on EF, if none listed today’s date iv. Provider Auth Expiration Date: Leave blank as the provider signature never expires. 8. Review site notes for important handling instructions. 4) Patient information Page  Person Account/Contact/Benefits & Coverage: 1. Double check the spelling of the patient’s name in Fusion against the enrollment form. 2. Check that the date of birth is provided and that in Fusion matches the one on the enrollment form. 3. Make sure that Uninsured box is accurately completed. 4. Confirm the address on enrollment form matches the one in Fusion. a. Confirm that the contact is active. b. And that they have Primary Correspondence and Shipping address. 5. Confirm that we have the patient’s full policy information. a. Payer phone numbers can be obtained from either the payer tool, Payer Surveillance or on the internet. b. If it’s a Blue Cross Blue Shield plan: do, we have the 3-digit alpha prefix? If not, the file is missing information.

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