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Identify outdated ingredient costs prior to submitting the claim to the processor.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 and revenue enhancement
Verifies 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 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.
Help ensure compliancy for third-party negative formulary and narrow therapeutic programs in which certain drugs should not be interchanged by pharmacists.
Provide assistance with specific payer requirements, support pharmacy operations, reduce audit risks, and maximize reimbursement.
Third-party edits include audit alerts regarding payer day supply and refill requirements, as well as hard copy documentation guidelines.