Specialty Pharmacies

Specialty Pharmacy Medical Benefits Billing

In today's Specialty Pharmacy market the allocation of the benefit design is estimated to be 50% on the pharmacy benefit and 50% on the medical benefit. This means that half the time you are either billing the Pharmacy Benefit Manager (PBM) benefit or the Health Plan. The percentages will vary depending on the disease state(s) you support, but in either case, if you are a Specialty Pharmacy billing medical claims you are full aware of the additional pain that it creates. There is a lot more front-end work to verify eligibility, understand patient co-pay or even know if a pre-authorization is required. Medical billing typically means slower reimbursement, additional labor (different staffing skill-set), and most importantly another system to operate and support with claims and financial information all over the place (no centralized data).

Specialty Pharmacy Solution

The TransactRx Cross Benefit Platform provides a solution to this problem.

  • Submit your medical claims directly from you existing pharmacy system
  • Real-time eligibility and patient responsibility response using standardized NCPDP message codes
  • Benefit design rules and edits can be loaded and managed by the system
  • Cross Benefit coding and billing rules are built into the system
  • The TransactRx Cross Benefit Clearinghouse converts the claim into a properly formatted ACS X12 and submits to Medicare Part B or commercial payors using your existing contracts.
  • TransactRx manages the submission, collections and reconciliation of all claims. TransactRx pays you twice a month on all collections received within the previous cycle.
  • TransactRx provides you with a detailed remittance advice and an 835 file than can be easily downloaded directly into your pharmacy software system.

Specialty Pharmacies of all types that have a mix of claim processing needs that span both pharmacy benefits and medical benefits can lower billing and collection costs, increase efficiencies and remove one of the headaches from your business so that you can focus on patient care.