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  • Network Solutions

    Our high-speed network provides claims switching services for pharmacies and is designed to integrate into existing workflows. Includes claims processing and editing, e-prescribing, medical claims billing, and other services.
    • MedRx Network

      Medical claims billing for the pharmacy

      The MedRx Network offers a flexible platform for pharmacy billing commercial, Medicare and Medicaid claims such as durable medical equipment (DME), immunizations, and more. Extensive editing capabilities with clear messaging provide the tools for the pharmacy to easily correct claims to get paid quickly and accurately. Our denial management services work underpaid and denied claims through to final determination. In addition, the MedRx Network features a customizable solution that reduces the risk of audits and encourages patient adherence and compliance.

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    • Pharmacy Network

      Real-time claims switching for efficient workflow

      The Pharmacy Network provides comprehensive, flexible solutions for pharmacy claims processing. Our claim switching service provides access to all U.S. third-party processors and allows real-time insurance verification. Our comprehensive solution allows you to efficiently switch claims, securely route prescriptions, and target patient adherence through point of sale messaging and electronic copay programs. Additional web-based tools allow transparency into claim information for analysis and reporting.

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    • Rx Claim Advisor

      Intelligent prescription claim editing services

      Working in tandem with our claims switching service, Rx Claim Advisor is a comprehensive pharmacy claim solution designed to increase third-party reimbursements and improve in-store productivity. Our intelligent edit engine provides real-time pre and post edits on prescription claims prior to being sent to and received from the processor. Clear messaging identifying potential problems and suggestions is provided for those requiring pharmacist intervention. Risks associated with compliance and audit programs are identified to help reduce submission errors. It will also help you easily identify, reverse, and resubmit claims that have been paid based on outdated average wholesale pricing (AWP). Additionally, our prescriber eligibility and patient commercial coverage alerts will help you reduce the risk of audits by identifying ineligible prescribers and state Medicaid claims that should have been billed to another plan. Our online support tools will provide real-time financial management and compliance reports to make business analysis easy.

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  • Commercial PBA Solutions

    A flexible platform for pharmacy claims adjudication, discount prescription programs, and other services that enable clients to improve claims processing efficiencies and better control prescription drug costs.
    • Smart PBA

      Adjudicate claims in real time and manage the process

      Smart PBA provides an intelligent platform for effective pharmacy claims adjudication and management.

      Our proprietary systems are rich in features, highly configurable, and support client-customized programs. Client types supported include: PBMs, TPAs, Discount Rx, Workers Compensation, and Pharmaceutical Manufacturer Programs.

      Additional administrative services available include Pharmacy Network, Payment Administration, Pharmacy Call Center Support, Plan Setup, Data Warehouse, and Formulary Rebates.

      Transactions for your pharmacies are adjudicated in real time according to your benefit plan design. The Windows-based, easy-to-use system fits any benefit plan design and easily adapts to changing needs.

      Additional support is available for customer service call centers, network administration, and rebate management.

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  • Medicaid PBA Solutions

    Change Healthcare offers clinically driven, evidence-based pharmacy benefit services, clinical services, and secure data and storage services specifically for State Medicaid and other related programs.
    • Pharmacy Claim Advisor

      Comprehensive claims management

      Pharmacy Claim Advisor provides real-time claims adjudication, management, and services for state Medicaid programs. Comprehensive capabilities include prior authorization workflow (electronic and manual), drug reference data and rules management, retrospective drug utilization review, SMAC workflow, web-based portal, helpdesk call management, and reporting. NCPDP and HIPAA-compliant pharmacy claims are transmitted to the processor, where client-specific rules and criteria can be applied. Automating these processes maximizes efficiency and drives cost savings.

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    • Rebate Insight

      Comprehensive set of tools for administration, contracting and reporting for drug rebate programs

      Rebate Insight is a comprehensive set of tools to help manage drug rebate programs. It includes smart workflow processes that minimize the complexities of multiple contacts for manufacturers and associated labelers. Its web-based interfaces streamline program administration and reporting to help you maximize cost savings and increase cash collections. Fully compliant with all state and federal guidelines, Rebate Insight can also be customized to meet each state’s unique needs.

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    • Program Integrity View

      Case tracking and management to assist in the audit process

      Program Integrity View is a stand-alone case tracking and management tool designed to assist in fraud, waste and abuse audit/review process. As a repository and notification system for all audit case activities, it records and notifies you when certain actions have taken place as well as next steps and due dates in the process.

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    • Authorization Advocate

      Generates and tracks correspondence to prescribers

      Authorization Advocate, formerly a Goold product, facilitates clinical review and processes prior medical authorizations. Its powerful document management capabilities generate and track a wide range of correspondence to prescribers via fax or mail. This correspondence can include authorizations for durable medical equipment, select medical procedures, physician-administered drugs, hearing aids, and chiropractic care.

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    • Rx Care Advisor

      A web-based patient case management tool

      Rx Care Advisor, formerly a Goold product, helps facilitate the operation of complex care management programs. This application supports clinical and administrative staff in managing various programs such as Intensive Benefits Management, Medication Therapy Management Program (MTMP), Therapy Compliance, and other programs requiring case management.

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    • Community Assessment

      Medical eligibility assessments for state-based, long-term care

      Community Assessment, formerly a Goold product, provides timely and objective eligibility decisions for long-term care and Medicaid-funded home care programs. We educate members and families about their choices and provide support with fair allocation of resources based on need. Our field nurses perform objective assessments wherever the patient may be located.

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