Obsolete NDC Edit
eRx Edit™ will analyze each claim and verify the NDC number of the drug submitted by comparing the submitted NDC number to a list of obsolete NDC's. If a NDC is found to be obsolete, the system will reject the claim and send a message to the pharmacy. The rejection message alerts the pharmacist that the submitted NDC number is out of date and has been replaced by a new NDC number and provides the pharmacy with the new NDC number to submit to ensure proper payment of the claim.
Benefit: This edit reduces costs by eliminating multiple rejections by the processor, as well as reducing the time needed to research for the new NDC number. Edit is also recorded and included in Web based reporting for viewing or download.
DEA Edit
eRx Edit™ will verify that an appropriate DEA number is being submitted. eRx Edit™ monitors each claim and checks the physicians DEA being submitted and if an inappropriate DEA number is identified, it will record/reject the claim and generate a report at the end of the monitoring period noting the DEA number submitted was not valid.
Benefit: This provides every pharmacy with the confidence that appropriate DEA numbers are submitted and compliance with federal DEA regulations are being met. Edit is also recorded and included in Web based reporting for viewing or download.
DAW Edit
eRx Edit™ will analyze each claim and check the submitted drug for generic availability and proper DAW code usage. If eRx Edit™ determines improper DAW code usage, the system rejects the claim and sends it back to the pharmacy for drug or DAW modification.
eRx Edit™ performs checks on three separate DAW edits. They are as follows;
Multi-Source Brand Drugs not submitted with DAW 5
(Substitution Allowed – Brand Drug Dispensed as a Generic)
Generic Drugs submitted with DAW 1
(Substitution Not Allowed by Prescriber)
Brand Drugs, with generics available submitted without a DAW code.
Benefit: These edits will maximize profits by insuring that proper DAW codes are used for the category of drugs dispensed. Edit is also recorded and included in Web based reporting for viewing or download.
AWP Edit
eRx Edit™ will verify that the most up-to-date AWPs are being submitted for claims.
eRx Edit™ will apply logic (Defined By You) based on the value of the submitted ingredient cost.
eRx Edit™ compares the submitted ingredient cost to the eRx master drug database ingredient cost. If the eRx ingredient cost is higher, eRx Edit™ will replace the submitted ingredient cost with the eRx ingredient cost.
If the difference between the submitted ingredient cost and the eRx Edit™ ingredient cost is greater than either store or plan based ‘maximum AWP difference level’, the claim is rejected.
You may define the edit by store, plan and submitted basis of cost.
The AWP edit has two different modes of operation that the user can chose from. The user can have eRx Edit™ reject the claim if the submitted ingredient cost is outside the users parameters or replace the ingredient cost submitted by eRx Edit™
Benefit: This edit will maximize profits by insuring that the proper ingredient cost is submitted. Updating ingredient costs at the pharmacy will also ensure that pharmacies using ingredient cost to calculate cash pricing have the most up-to-date cost information. It will also reduce the time needed to research updated ingredient costs and provide Web based reporting or download to identify third party, drug pricing trends.
Reimbursement Edit
eRx Edit™ will compare the adjudicated amount to be paid by the third party to the submitted amount from the pharmacy. If the difference between the adjudicated amount and the submitted amount is less than the customer defined threshold, eRx Edit™ sends a message to the Pharmacy to alert them of a potential reimbursement problem. This post-adjudication edit allows the pharmacy to easily identify problem claims or plans to ensure maximize claim reimbursement.
Benefit: This edit will alert the pharmacy to any potential reimbursement issues and will maximize profits to the pharmacy by identifying potential underpayments to the pharmacy. Edit is also recorded and included in Web based reporting for viewing or download.
Usual & Customary(U&C) Edit
eRx Edit™ will compare the adjudicated amount to be paid by the third party to the submitted usual and customer amount from the pharmacy. If the adjudicated amount paid is equal to the submitted U&C amount, eRx Edit™ sends a message to the pharmacy to alert them that the claim was paid at U&C.
The user has the ability to either turn on or off this edit at a plan specific level.
Benefit: This post-adjudication edit allows the pharmacy to easily identify claims that are paid at U&C and to evaluate if their cash price is correct. The edit is also recorded and included in Web based reporting for viewing or download.
eRx EditTM is a trade mark of eRx Network, LLC
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