Available to DetectRx customers for an additional fee
Payer Response Transparency (PRT)
There are instances where pharmacies are submitting a claim to a commercial or government plan and, instead of sending a rejection to the pharmacy, the payer “flips” the transaction so that the response is from a cash discount card. This is being seen in claims that should be denied for:
• NDC Not Covered
• Coverage Terminated
This paid response from the payer includes the cash discount card information but this change in payer type is not apparent to the pharmacy.
• In turn, the pharmacy may receive a lower reimbursement from the cash discount card compared to that of a commercial or government plan, as well as be charged an administrative fee.
• The pharmacy is losing transparency into when coverage is terminated or a NDC is not covered; therefore, they cannot intervene to resolve.
• The pharmacy may attempt to complete a COB claim (to Tricare, Medicaid, etc.) thinking that the primary was paid by the commercial or government plan.
• Pharmacies often need NDC Not Covered rejections from Medicare in order to process claims under Medicaid instead (especially for OTCs).
• Potential negative impacts to other services a pharmacy has enabled (Price Check, Denial Conversion, and Continuity Of Care).
How PRT Works:
Benefits of the PRT Program:
• Alerts pharmacy in real-time (by way of rejection message) that a cash discount card was used for reimbursement by the payer instead of the commercial or government plan the pharmacy submitted the claim to while simultaneously reversing the claim.
• Equips pharmacy staff with actionable messaging on next steps that should be taken according to the customer’s requirements.
• Enables pharmacy with transparency into reimbursement and patient awareness actions that can be performed before a prescription leaves the pharmacy.
• Reporting may offer helpful insight for payer negotiations.
