Boost income and efficiency
- Provide proven, real-time pre- and post-edits as prescription claims are routed to and received from the third-party processor.
- Override a suggested edit to allow a claim to process without an update.
- Identify outdated ingredient costs prior to submitting the claim to the processor.
- Perform a series of post-edits with specific messages added to the claim response for review.
Real time pre- and post-claim edits
Financial savings
Financial savings and revenue enhancement
- Verifies that current ingredient cost is submitted on each claim by comparing the price in the third-party file, updated daily. If the price in file is higher, the price is automatically updated before submission.
- Identifies inappropriate quantities for products dispensed as milliliters, grams or total packs and messages with suggested proper pack sizes.
- Identifies claims submitted with a discontinued NDC based on customer-defined thresholds, giving the pharmacy time to work through its inventory following discontinuation.
Audit compliance
Audit and regulatory compliance
- Validate prescriber identifiers and check for conditions such as DEA or NPI identifiers that have been expired for greater than 30 days or that are invalid.
- Evaluate commonly audited products for specific fields such as day supply, new prescription requirement and date written.
- Detect suspect combinations of products and DAW fields likely to lead to under-reimbursement or audit risks. These edits also help monitor many state-specific regulations around acceptable DAW usage.
Operational assistance
Assistance with specific payer requirements
- Helps ensure compliance for third-party negative formulary and narrow therapeutic programs in which certain drugs should not be interchanged by pharmacists.
- Provides support for pharmacy operations, reduce audit risks and improve reimbursement.
- Third-party edits include audit alerts regarding payer day supply and refill requirements, as well as hard copy documentation guidelines.
Industry insights
Case study
See how a leading health plan reduced costs, improved outcomes and strengthened provider relationships with a modern post-acute care model.
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White paper
See how in-home technology helps payers give better care, solve social problems and improve health for people who need it most.
Report
The proposed changes contain a mix of both opportunities and challenges. Read the report to learn how these changes could impact your organization.
Complementary solutions
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Rx Connect™
Our claims switch adjudication network allows pharmacies to send claims in real time to any U.S. third-party processor.
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Rx Assist
Our dynamic copay assistance and messaging platform helps deliver real-time prescription savings and educational messaging to patients.