Pre and Post Prescription (Rx) Reviews
Overview
This secure online service is designed to help pharmacies reduce costly Third Party claim submission errors and to provide a powerful and comprehensive overview of claims dispensed by the pharmacy.
Reviews and edits are configured to meet your business needs then applied before the claim is adjudicated and also applied when the claim is returned by the processor for complete accuracy, patient safety, and maximum profitability.
Pre Rx Review Suite
The pharmacy receives an on-screen notification when the review is complete, but claim is processed as usual. Review reports are available on the pharmacy's website the day following the review:
- Pre-AWP Ingredient Cost Review - Claims that are received with a submitted AWP lower than the published AWP (Average Wholesale Price) will be raised automatically to the highest AWP.
- Pre-Usual and Customary Review - Claims are reviewed when the submitted U&C is lower than the published U&C for pharmacies within the submitter's Zip Code area.
- Discontinued NDC Review - The submitter is shown current NDC numbers when submitting a drug that has changed or has been discontinued.
- Market Share Formulary Review - Claims are reviewed against the National Market Share Formularies to determine if rebates could be earned using formulary drugs.
Post Rx Review Suite
The pharmacy receives an on-screen notification when the review is completed after processing by the Third Party payor. Review reports are available on the pharmacy's website the day following the review.
- Generic DAW Review - Claims submitted with a DAW of 0 or blank are reviewed to determine if a pharmacy will receive higher payment if alternate DAW codes are submitted for the same claim.
- MAC Pricing Review - MAC price submitted is compared to MAC price paid and to Ingredient Cost submitted for inconsistencies.
- Usual & Customary Review - Submitted U&C is compared to average U&C for a pharmacy's Zip Code area.
- Payor's Highest Response (PHR) Review - This compares the Total Amount Paid against all other submitted claims for that Third Party Contract and reports any inconsistencies.
Pre-Hard Edit Reject Suite
FDS will reject all claims that exceed parameters set by the pharmacy. The pharmacy may choose to reject a claim for whatever reason and make it necessary to enter a prearranged override code (password) that is tracked with every use.
The pharmacy may choose to have hard edit rejects performed, but not make it necessary to enter an override code (password) by simply striking one key to send the claim on.
The pharmacy may also assign percentage values to rejects to allow for submission of claims that fit within broader criteria (e.g., rejecting any claim that has a submitted U&C 10% lower then the published U&C). Reports are available daily on the day following the edit/rejects.
- Pre-Hard Edit DAW Reject - Claims submitted are compared to PHR DAW and rejected if the PHR DAW payment is higher. Pharmacy may set a "within this percentage value" for this reject.
- Pre-Hard Edit Usual & Customary Reject - The submitted claim's U&C is compared to the FDS average U&C and rejected is it is lower then a previously submitted U&C. Pharmacy may set a "within this percentage value" for this reject.
- Pre-Hard Edit Payor's Highest Response Reject - The claim is compared to the PHR for the identical drug and contract and is rejected when the PHR is higher then the submitted claim. The pharmacy may set a "within this percentage value" for this reject.
- Pre-Pharmacy Specific Formulary Reject - The pharmacy is able to set their own formulary based on dispensed quantities, acquisition cost, availability, and other criteria.
- Pre-Hard Edit TEE Reject - This compares all multi-source drug submissions for therapeutic equivalency and rejects claims that will be paid using generic pricing for brand name drugs.
- Reject Previous Rejection - Rejected claims will receive a "previously rejected" message which will need to be overridden to allow resubmission.
- Batch Submission Override - The pharmacy may choose to receive Rx reviews when submitting batched claims. Batch submissions are treated as one claim which are all rejected if one claim in the batch is rejected, the pharmacy may choose to exclude hard rejects from batch submitted claims. The pharmacy will still receive hard rejects on single claim submissions and reviews on batch submissions.
Freedom's Members Enjoy Up-To-Date Online Reports
Pre and Post Rx Reviews Reports allow members to view claim reviews performed on all claims submitted for the previous 30 days. Members will view claims that have been submitted with incorrect ingredient costs, Usual and Customary (U & C) pricing, old National Drug Code (NDC) numbers, or that did not adhere to the National Market Share Formulary. Members may also check payments with Dispense As Written (DAW), Maximum Allowable Cost (MAC), U & C, and Third Party cost adjudication.
Click to display or hide a larger image of an online report (56kb).
