Prescription Drug Claims

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:

  1. Approved - the claim was approved for payment by the plan for the product dispensed to a patient.

  2. 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.

  1. 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.

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