Rx Edit

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

Boost Income, Efficiency

Provide proven, real-time pre- and post-edits as prescription claims are routed to and received from the third-party processor. 

Identify outdated ingredient costs prior to submitting the claim to the processor.

Override a suggested edit to allow a claim to process without an update. 

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.

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