Skip to main content

Rx Edit

Increase third-party reimbursements and improve in-store productivity with this comprehensive pharmacy claim solution.

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  • Identify outdated ingredient costs prior to submitting the claim to the processor.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.

Related healthcare insights

Subscribe to newsletters

Get top healthcare news, executive insights, research and analysis delivered directly to your inbox.

White paper

Outlook on oncology 2024

See how emerging trends, including a global pandemic, are reshaping the landscape of oncology care and medication.

Article

Reconcile your RWD expectations to maximize your investment

Understand how routine clinical practice impacts information captured in real-world data (RWD).

Let’s start a conversation

Complementary solutions

Rx CardFinder™ Services

A pharmacy eligibility service that checks patient coverage with the nation’s largest Pharmacy Benefit Managers (PBMs) and returns real-time responses.

Rx Connect™

Our claims switch adjudication network allows pharmacies to send claims in real time to any U.S. third-party processor.

Rx Assist

Our dynamic copay assistance and messaging platform helps deliver real-time prescription savings and educational messaging to patients.