Counter Guide
Working a rejected claim
Claim cases hold the original rejection text, a manual classification, and the chosen next step. Refillops helps organise the work — it does not approve coverage or decide which medication is appropriate.
When to use this
- When a claim rejection comes back from the payer with a reject code or free-text message.
- When the same patient is bouncing between rejection types and you need a clean history.
- When a rejection looks like it needs a prior auth, a prescriber call, or a patient conversation.
Step by step
- 1
Create a claim case
From Claims → New case, link the patient and the prescription reference. Add the date the claim was submitted and the date the rejection was received.
- 2
Add the rejection text
Paste the full rejection text or reject code exactly as the payer returned it. Do not paraphrase — the original wording is what payer follow-up calls reference.
- 3
Classify the rejection manually
Pick a category: Prior auth required, NDC/quantity issue, Refill too soon, Coverage limit, Coordination of benefits, Drug not covered, Other. Pharmacy intelligence may suggest a category; the pharmacy team confirms.
- 4
Create a PA case when needed
If the rejection points to prior authorization, click ‘Create PA case’. This links the claim and PA case together so the timeline stays joined.
- 5
Draft prescriber or patient updates
Use the side panel to draft a prescriber message or a patient update. Every draft is editable and must be reviewed and sent by the pharmacy team — Refillops never sends on its own.
Common mistakes
- Editing the rejection text to make it ‘cleaner’ — keep the payer’s original wording.
- Choosing the closest-sounding category instead of ‘Other’ when nothing fits.
- Sending the AI-drafted prescriber message without checking the medication name and directions.
Safety & trust
Refillops does not decide coverage, approve denials, recommend therapy substitutions, or replace pharmacist judgment. Use it to organise work and draft language for human review.
Still need help?
Contact Refillops support and we’ll get back to you.