NESP Centene Patient List Communication
Nebraska Total Care Member Opt Out and Patient Opt In Requests
Pharmacy Name
Pharmacy NPI
NTC Member Name
First Name
Last Name
Member Birthdate
-
Month
-
Day
Year
Date
Nebraska Total Care Member ID
Reason for Status change request
Patient Opted Out
Patient doesn't fit criteria
Patient would benefit from Chronic Care Mgmt and we think we can get 2:1 ROI
Patient is a LTC patient
Patient is getting off Medicaid or is newly dual eligible
IF member opted out, what was their reason?
Member Name
First Name
Last Name
Member Birthdate
-
Month
-
Day
Year
Date
Nebraska Total Care Member ID
Member Status Update
Please Select
Member has opted out,We would like to add Member,We don't think member meets qualifying requirements
Reason for Status change request
Patient Opted Out
Patient doesn't fit criteria
Patient would benefit from Chronic Care Mgmt and we think we can get 2:1 ROI
Patient is a LTC patient
Patient is getting off Medicaid or is newly dual eligible
IF member opted out, what was their reason?
Member Name
First Name
Last Name
Member Birthdate
-
Month
-
Day
Year
Date
Nebraska Total Care Member ID
Member Status Update
Please Select
Member has opted out, We would like to add Member, We don't think member meets qualifying requirements
Reason for Status change request
Patient Opted Out
Patient doesn't fit criteria
Patient would benefit from Chronic Care Mgmt and we think we can get 2:1 ROI
Patient is a LTC patient
Patient is getting off Medicaid or is newly dual eligible
IF member opted out, what was their reason?
Any additional communication/comments
Configurable list
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NTC Patient Claims below cost
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