COLLEGE OF PHARMACY

Pharmacy Informatics
and Healthcare Data
Analytics
Week 4 Pharmacy
claims data in PBM/
Health plan
Week 4

• Positive feedback on the lectures

• Break out lectures into a couple smaller lectures
• Questions asking about insurance claims and what happens at
the PBM/Health plan
Objectives

• Pharmacy data and claims processing is extremely complex

• Provide a high level overview of claims and the associated
data components
Background of a claim

• A medical claim is an invoice a doctor, or medical facility,

sends to a health insurance company after a patient receives
care. It provides details on the services the patient has
received and the associated charges set by the doctor, or
facility
• Claims processing is an intricate workflow involving
checkpoints that every claim must go through before it’s
approved. If a claim makes it through all these checkpoints
without issues, the insurance company approves it and
processes any insurance payments. If it doesn’t, it gets
denied, or sent back for more information
https://firstcoasthealthsolutions.com/pharmacy-claims-processing/
Life cycle of a claim
www.slideshare.net/nitinsaini12/lifecycle-of-a-claim
Minimum Data fields

• Specified minimum data fields are required to submit a

claim
• Pharmacy claim
• Member info
• NDC
• Quantity
• Days supply
• Prescriber
• Insurance information
At the PBM

• Claims goes thru a series of steps

• Check of member eligibility
• Check of member benefits
• Check if product is on formulary
• Check if product has any utilization management (PA, ST, ect)
• Check if product has any pharmacy restrictions (specialty)
• Check pricing tables for appropriate reimbursement (MAC, AWP,
ect)
• Claim status can change at any of these steps
Eligibility file

• Provided by the health plan to the PBM

• PBM loads the file
• File of all members covered
• ID numbers
• Patient Demographics
• Which specific plan they fall under
• Updated constantly
• Can be a source of rejections if not handled properly
Benefit information

• Employer may offer multiple types of insurance to their

members
• At my job
• PPO
• High deductible health plan
• HMO
• Each type of insurance can have different copays, deductibles,
and medication exclusions
• All that information is loaded with the PBM to ensure
appropriate adjudication of claim
Formulary information

• Loaded by the PBM

• Can be done at different drug identifier levels
• NDC
• GCN
• RXCUI
• GPI
• Applicable edits are applied to drugs. PA, QL, AL, ect
MMIT

• Managed markets insight and technology

• For nearly two decades MMIT has been solely focused on
solving the “what and why” of drug coverage, and has been
a trusted, go-to-market partner to pharma companies,
payers and providers
• Based in Philadelphia area
• Tool called formulary navigator
• Searchable formulary tool

www.mmitnetwork.com/life-at-mmit/
Formulary Navigator
Formulary navigator
Formulary Navigator example QL
Formulary Navigator example age edit
Formulary Navigator Maintenance

• Tool requires maintenance as formulary changes

• Can change one drug
• Can do a bulk upload via excel template
• Multiple drugs
• Entire formulary
• Can make changes via drug name, or drug identifier (NDC, GCN
ect)
• “Proxy” product selection
Formulary Navigator uses

• Searchable formulary link

• Placed on health plan website
• Allows for providers, pharmacies, members to search for
medications
• Has details on tiering, PA, QL, ect
• Allows for pulling comprehensive formulary in PDF, excel or
word
• Allows for pulling formulary information for submission to
regulatory bodies like CMS
Pharmacy Restrictions

• Insurers may opt to restrict medications to certain

pharmacies
• Some states have laws prohibiting this
• Any willing provider laws
• May be done for financial or clinical reasons
• Often seen with specialty medications
• Any restrictions are built into claims processing system
• Typically done at the pharmacy NPI level

www.ncsl.org/research/health/any-willing-or-authorized-providers.aspx#:~:text=“Any%20Willing%
20Provider”%20statutes%2C%20sometimes%20referred%20to%20as,networks%20of%20providers%20if
%20certain%20conditions%20are%20met
.
Pricing

• Pricing is complex
• Pharmacy reimbursement for medication
• Typically a dispensing fee
• May be administration fee (vaccine)
• Member cost share (as applicable)
• Flat copay
• Co-insurance
• Pre meeting deductible
• Post meeting deductible
• Pricing may even go down to the NDC level
Reporting

• Any information on a claim becomes reportable

• Drug
• Member
• Prescriber
• Pharmacy
• Reimbursement
• Date
Who does reporting?

• Most areas
• Formulary team
• MTM team
• Network team
• Fraud waste and abuse team
• Prior authorization team
• Informatics team
• Handles more complex reporting
Reporting example

• Negative formulary changes

• May require notification of member in advance
• Formulary team
• Reports can be run using date, member, drug to determine who
would need a letter sent to them describing the change and
potential alternative medications
• Would also need applicable information to do a mailing
• Member name
• Address
• Zip
• Ect
Conclusion

• Pharmacy claims processing is extremely complex

• Enormous amounts of data are required to set up benefits
and claims processing
• Enormous amounts of data become available once claims are
processed
• Data has a wide variety of uses