Medical Claims Services
(Specialty Drugs & Injectables)
Health plans that cover drug services under the member’s medical benefit plan represent a significant revenue source for the pharmacy industry.  Medical Claims Services enables pharmacies to prepare, validate and submit claims for medical services that are covered by the member’s medical benefit.  Pharmacies use their existing practice management systems (dispensing systems) to submit medical claims just like other third-party prescriptions - no additional hardware or software is required.  Upon receiving the claim, OmniSYS performs over 400 prospective edits to ensure claims are “clean” before they are mapped and, subsequently, submitted as medical claims to appropriate payors.  Medical Claims Services create new revenue opportunities for community pharmacies interested in providing these services.

Pharmacy trading partners rely on standards established by the National Council for Prescription Drug Programs (NCPDP) while Health Plan trading partners rely on ANSI Standards.  The majority of claims for drugs dispensed by pharmacies are billed using the NCPDP Standards; however, an increasing number of specialty injectable drugs and other high-cost medications dispensed by community pharmacies are covered as a medical benefit and must be billed in a medical claim format.  OmniSYS bridges the gap between these disparate billing methodologies by seamlessly mapping “pharmacy” claims to “medical” claim formats prior to submission for payment. 

Medical Claims Service Options offered by OmniSYS
The processing of Medical Claims including specialty drugs must be understood to ensure that the pharmacy will be paid for its services.  Requirements surrounding the servicing of these claims are often very complex.  OmniSYS’ Medical Claims Services are designed to provide community pharmacies with a suite-of-services that are needed to successfully pursue reimbursement of medical claims including specialty drugs. 

These service options include:

• New Patient Enrollment
• Pharmacy Interface
• Prior Authorization Management
• Medical Claim Submission
• Refill Certification
• Claim Preparation
• Claim Editing
• Patient Billing
• Financial Reporting