RJ’s Automated Medical Drug Edits Provided Corrected Values for over 50% of Submitted Claim Lines

Drugs covered under medical benefit plans and their costs are difficult to manage.

These challenges are due to:

•  Limited clinical visibility and control

•  Unaccommodating medical claims and claim systems

•  Complex billing and reimbursement requirements related to coding and pricing

As a result, medically covered drug claim errors are almost the norm.  In a study of RJ Health 2018 client claim data, the application of RJ Health Medical Claim Edits resulted in the real-time provision of corrected values for over 50% of submitted claim lines.

In fact, automated medical drug edits can be applied prior to claim submission or adjudication to assure:

•  Accurate unit cost management for all drugs covered under the medical benefit

•  Appropriate pricing methodologies and fee schedules

•  NDC to HCPCS/CPT alignment and billable unit conversions

•  Dose limit accuracy for both FDA and Compendial indications

•  The utilization of NDC pricing for drugs aligned with NOC Codes

•  Accuracy in these areas will reduce appeals, delayed payments, and improper reimbursement, particularly for claims with NDC mandates for both Government & Commercial memberships.

We invite you to send us some sample claims data to help you size the ROI opportunity for your organization.

For more on RJ Health’s Medical Drug Edits and API services, view our on-demand webinar:

Creating Pre-Payment Controls for Medically Covered Drug Costs through Automation

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A discussion on medical benefit drug management challenges and opportunities for pre-payment automation within your organization.


To view the transcript and deck, CLICK HERE.