Pharmaceutical companies rely on business intelligence to monitor sales success of their drug(s). Managed care plays an important part in positioning their product(s), and affordability to the patient.
A claim is defined as a prescription (Rx) drug that is submitted for payment (electronically or manually) on a covered product.
A claim can have one of three statuses:
Approved - the claim was approved for payment by the plan for the product dispensed to a patient.
Rejected - these claims are plan driven, with no product dispensed. The Plan/PBM/Processor alerts the pharmacist that the claim has been rejected and the reason why.
There may be several rejection transactions associated with a claim.
Pharmacist may resubmit the rejected claim with corrections, or substitute another product that is more likely to be approved.
Reversed - these claims are patient driven, with no product dispensed.
Reversed transactions follow an approved transaction (see # 1).
Common reasons for a pharmacist to request a reversal
Drug’s co-pay (price) is too high for the patient.
Patient has a brand loyalty, and the pharmacist attempted to substitute a generic.
Patient did not appear at the pharmacy to pick up their filled prescription within a week or so, and the pharmacist placed the product back in stock.
Patient elected to use an alternate benefit/insurer after the pharmacy has already transmitted the claim to the presented or primary plan/insurer of record.