Claims And Program Management
KapitalRx claims processing platform features ensure flexible claims management functionality and support comprehensive program management:
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Dual Coverage
Members and dependents are indexed and stored based on the member ID, group ID, account ID, and carrier ID under which they are added to the system. As such, a member may be in the system multiple times, allowing for dual coverage and the separation or accumulation of benefits.
Overrides
The system’s robust prior authorization capabilities allow for overrides to be placed for early refill, vacation supply, etc. Overrides can be placed for any edit in the system, with appropriate documentation regarding your procedures, to immediately override a non-covered drug and charge a copay you designate for a specific patient.
Eligibility Tracking
Each member’s update(s) is tracked separately, and the database has a unique self-documenting/auditing feature that enables users to see how each update was applied and how the eligibility information changed over time. Roll logic and a comprehensive audit trail are built into the application, making it clear which benefit was in effect and used during the actual adjudication process.
National Physician Identification (NPI) Implementation
We can help you in transitioning to NPI. Our system fully supports the NPI to identify the provider (pharmacy) and the prescriber on the submitted drug claim. Additionally, the system allows alternate provider/prescriber identification codes including DEA numbers, state license numbers, company-assigned ID numbers, and any number of other enumerations.
Physician Identification
We can support and load company-specific prescriber files. New prescribers are quickly and transparently added into the system.
Operational and Audit Trail Reports
Operational reports produce summary totals for prescribers added and those who have been updated. We also produce detailed reports with details on changes in key fields for prescribers who have been updated. The report can show which network of prescribers has been affected by maintenance activity.
OTC Drug Product Management
Designate as eligible for coverage as few or as many Over-the-Counter (OTC) products as you choose. OTC claims are processed in the same manner as other electronically-submitted pharmacy claims and are subjected to plan edits and benefit parameters (including different cost-sharing logic) that you determine for your plan. Specific classes or categories of products can be excluded or treated differently during the adjudication process. NDC codes can be added to the system to support store brands not listed in the available product reference files.
Explanation of Benefits (EOBs)
We produce EOBs for every direct member reimbursement claim via a variety EOB templates or a customized EOB. We can produce and mail EOBs on a weekly basis or other mutually agreeable cycle basis.
Management of Online Claims History
We retain all history data in the system for any agreed-upon term and can store virtually any amount of data on the system.
Coordination of Benefits (COB)
The system allows for COB adjudication. If you elect COB processing, the applicable member record ID is “flagged” to indicate the patient has alternate insurance. The presence of industry standard values in the Other Coverage Code on the claim submitted by the pharmacy determines if the claim is allowed or not allowed to adjudicate for that member. If the Other Coverage Code indicates the claim is primary, but the member ID submitted is secondary, RxClaim will attempt to locate the member’s primary record on the system before rejecting the claim. Through plan setup, you define if alternate pricing or patient pay calculations should be performed on the claim processed as secondary.
Payment Options
The system allows an almost infinite combination of payment options and scenarios that can be adopted to meet your specific requirements.
Pharmacy Messaging
We offer comprehensive capabilities for online, point-of-service messaging that helps promote appropriate claims processing and drug utilization. In addition to providing online alerts for standard National Council of Prescription Drug Programs (NCPDP) rejection codes, our claims system accommodates customized or enhanced messaging, such as alerts for specific drug-level warnings or tailored messages that accommodate your plan design.