We offer an advanced, real-time pre/post edit service that helps improve reimbursement. Our edits include:
DataRx Edit will verify that the most up-to-date AWPs are being submitted for claims.
DataRx Edit will apply logic (defined by you) based on the value of the submitted ingredient cost.
DataRx Edit compares the submitted ingredient cost to the DRX master drug database ingredient cost. If the DRX ingredient cost is higher, DataRx Edit will replace the submitted ingredient cost with the DRX ingredient cost.
If the difference between the submitted ingredient cost and the DataRx 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 from which the user can choose. The user can have DataRx Edit reject the claim if the submitted ingredient cost is outside the user’s parameters or replace the ingredient cost submitted by DataRx Edit.
Benefit: This edit will maximize profits by ensuring 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 downloads to identify third party, drug-pricing trends.
DataRx Edit will analyze each claim and check the submitted drug for generic availability and proper DAW code usage. If DataRx Edit determines improper DAW code usage, the system rejects the claim and sends it back to the pharmacy for drug or DAW modification.
DataRx Edit performs checks on three separate DAW edits. They are as follows:
Multi-Source Brand Drugs not submitted with DAW 5
Benefit: These edits will maximize profits by insuring that proper DAW codes are used for the category of drugs dispensed. The Edit is also recorded and included in Web based reporting for viewing or download.
DataRx Edit will compare the adjudicated amount to be paid by the third party to the submitted usual and customary amount from the pharmacy. If the adjudicated amount paid is equal to the submitted U&C amount, DataRx 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 turn 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.
DataRx 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 an 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. The Edit is also recorded and included in web-based reporting for viewing or download.
DataRx Edit will verify that an appropriate DEA number is being submitted. DataRx 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. The Edit is also recorded and included in Web based reporting for viewing or download.
DataRx 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, DataRx 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 maximum 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. The Edit is also recorded and included in web-based reporting for viewing or download.