Software

Rx Edit

A comprehensive pharmacy claim solution designed to increase third-party reimbursements and improve in-store productivity.

 

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  • Identify outdated ingredient costs prior to submitting the claim to the processor.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

  • Operational Assistance

    • 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.

Our outcomes

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