Post-Service Pre-Payment Claim Edits

Post-service pre-payment claim edits

We apply claims editing logic that is designed to ensure claims are paid correctly for drugs billed on the medical benefit, using the same sophistication that can be applied under the pharmacy benefit in a highly-configured, automated process. Plus, our solutions are flexible and customizable to meet your plan’s unique goals! 

Eligible Diagnosis Edits

Eligible diagnosis edits guarantee the correct ICD-10 coded claims are paid within an acceptable range of FDA-approved indications, compendia-approved uses, and the current standard of care. 

Maximum Units Edits

Maximum units edits allow payment within an expected range—yet not above calculated maximums—specific to each unique indication for that drug. 

Duration and Frequency Edits

Duration and frequency edits ensure claims are being paid for the appropriate length of therapy and frequency within a cycle. 

Patient Specific Edits

Patient specific edits confirm the dose and frequency authorized in the PA matches the claims submitted. 

The power of integration

ask us how we can develop targeted solutions to optimize appropriate use, adherence, and cost management for high-cost specialty drugs on the medical benefit.