Pharmacy claims reconciliation plays a vital role in the efficient functioning of the healthcare system, particularly in the area of pharmacy claims processing. Reconciliation is the process of matching the point-of-sale adjudication, also known as the promise-to-pay amount, from the third-party payer to the amount actually paid. The electronic remittance advice (ERA) , or 835, is the electronic transaction that provides detailed claims payment information, and can include information about adjustments and denials of payment for pharmacy services. It is an essential tool for pharmacies to use to reconcile their claims and ensure accurate reimbursement. Understanding the nuances of 835 fees and adjustments is crucial for pharmacists, pharmacy technicians, and other healthcare professionals involved in the pharmacy billing and reimbursement process, thereby allowing them to take proper action to follow contractual obligations, advocate for the health of the pharmacy industry, and have a firm knowledge of the financial strength of their business.
Learn more about Pharmacy Claims Reconciliation
What are Fees and Adjustments? The 835 transaction contains valuable information about fees and adjustments applied to pharmacy claims.
Fees refer to the amounts deducted from the original billed charges, which can include:
• Contractual fees, negotiated between the pharmacy and third-party payer
• Customer service fees
• In-network and out-of-network fees
These fees are reflected as deductions, allowing pharmacies to reconcile their financial records accurately. Read more >
Net-Rx™, an MHA Solution, has specialized in providing operational and software-driven solutions exclusively for pharmacies for more than 15 years. Led by industry experts, Net-Rx™ solutions drive operational excellence and optimum financial performance across reconciliation, reimbursement verification, and prescription pricing.
This post is related to:
Finance: Worker's Comp, Claims, PA Management, Adjudication
