Pharmacy Benefit Management

Patient Health First

Pharmacy Benefit Management

Claimpay’s PSAO (Pharmacy Services Administration Organization) provides effective solutions to assist pharmacy and physician owners in managing the business administration and financial components related to commercial pharmacy claim adjudication.

Claimpay’s PSAO is a highly respected Pharmacy Services Administration Organization (PSAO).

More than half of America’s independent pharmacies hire a Pharmacy Service Administration Organization (PSAO) to centralize, streamline and oversee certain administrative functions including PBM contract management and negotiations, accounts receivable collections, and cash management reporting.

Contact us today to learn how your pharmacy or practice can benefit by joining the Claimpay PSAO.

Managed Contracting Service

Claimpay’s managed contracting service encompasses more than 100 contracts. We aggressively negotiate each contract, handle provider enrollment, and perform all necessary maintenance to keep each enrollment active. More comprehensive management of the contracts can be provided when combined with Claimpay’s cash management and claim-by-claim reconciliation services.

We collectively bargain with pharmacy benefit managers (PBMs) to obtain the most favorable contract language for each pharmacy or practice. We also process the claims/billing information on behalf of independent pharmacies or practices. Throughout this process we have benchmarks and monitoring tools in place to ensure compliance with contract terms and to identify any specific claims which are not being processed in compliance with contractual terms.

  • PBM Contract Management Services includes contracts covering prescription drug programs for managed care, commercial insurance, Medicare Part D, long-term care, medication therapy management programs and vaccine programs.
  • Claimpay provides a professional review of each PBM contract to ensure that pharmacy provider rights are protected while abiding by the professional obligations of each PBM Contract.
  • Claimpay negotiates, modifies, updates, and enrolls individual dispensing locations into our network.
  • Claimpay will monitor and make their best effort to ensure timely payments from the PBM’s relative to the adherence by the PBM to their own payment processing cycles.
  • Claimpay can review and evaluate PBM contracts not currently held by MDSRx on your behalf.

PBM Cash Management Services

Claimpay implements rigid PBM Cash Management processes to provide you with the security and financial controls necessary to manage your business, providing the following services:

  • Utilize nine strategically located and nationally recognized regional wholesale lockbox service processing hubs.
  • Provide detailed and summary level reporting for all “Funds Transferred Reports” into your designated accounts including check number, vendor/payer name, check amount and date of export, on a daily basis. Detailed pharmacy remittance reports are included.
  • Provide monthly summary “PSAO Payment Report” for all monies transferred to the pharmacy.
  • Provide Automated Clearing House (ACH) payment services, directly depositing contract payments into your designated bank account.
  • Track, monitor, and archive all funds received from the insurance plans, PBM’s and/or other third party contracts, being managed under our NCPDP affiliation code.

Claim Level Reconciliation

Claimpay posts opens account receivable claim level data from their software vendor or from your pharmacy switch vendor. Once posted your claims data is reviewed for accuracy and completeness. Payment data detail is received, processed, and matched at the claim level (including RX number, fill date and other data elements to insure a unique one-to-one match occurs). This claim level reconciliation is how we identify underpayments, overpayments, non-compliance with contract terms/rates, provide necessary feedback to the PBM’s, and remedy any non-compliance issues.

Additionally, we utilize payment forecasting tools to know when payments are anticipated and whether or not they are compliant with contracted terms.

  • On a weekly basis, Claimpay imports and posts claims as an open item accounts receivable, for all of your claim data from your PBMs Insurance Plans and third party plans, and we verify and validate the data for accuracy and completeness
  • Post Payments received from the PBM’s, Insurance Plans and other third party payers
  • Conduct a one-to-one open item claim receivable matching process with the corresponding unique payment detail records.
  • Research and follow up on all outstanding claims
  • Archive all reconciliation data
  • Research and follow up on all rejected and denied payments
  • Research and follow up on all unmatched and underpaid claims (Suspense & Exceptions)
  • Provide a monthly summary aging of all unpaid claims by payer

Contact us and let us show you how DocRx and Claimpay can help you maximize reimbursements and get patients the medications they need and put the Patients Health 1st.