How can I reduce the amount of errors and the amount of time my team spends related to HCPCS/CPT and NDC codes?

How can I eliminate excess drain on my team related to inconsistent claims based on reimbursement policies and how that’s coded?

How can I enable my provider network to submit claims correctly using NDC codes and reduce the backlog of under/overages?

How can I manage formularies across all lines of business and all geographies?

How can I stay ahead of regulations and market trends that could impact my formularies?

How can I publish formulary documentation in the form of searchable websites and formulary guide PDFs?

Simplify Medical Pharmacy Coverage Management

Simplify Medical Pharmacy Coverage Management

Manage & Distribute Medical Pharmacy Coverage Data Across Members, Providers & Internal Teams.

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WHITE PAPERS

White papers to help you Control Medical Drug Spend.

WEBINARS

Webinars to help you Control Medical Drug Spend.

DRUG ALERTS

Specialty Drug Pipeline Review to help you Control Medical Drug Spend.

RJ Health Payer Solutions Business Questions

How can I reduce the amount of misaligned HCPCS/CPT and NDC codes my team deals with?
  • Comprehensive current and historical HCPCS/CPT® prices for medically covered drugs.
  • Accurate and comprehensive NDC to HCPCS/CPT® cross-walk data for medically covered drugs.
  • Avoid incomplete, out of date, or incorrect NDC to HCPCS alignment relationships, NDC Level AWP & WAC pricing and additional drug details useful in claim billing and adjudication.
How can I reduce the amount of inconsistent claims based on reimbursement policies?
  • Save on wastage and overbilling with maximum dosing and HCPCS/CPT® code unit limits and single dose information for high cost / high utilization medically covered drugs.
  • Reinforce HCPCS/CPT® alignment data for NDCs to capture savings and/or inform formulary development, pricing and reimbursement.
  • Save on specialty drug reimbursement and improve validation related to NDC units to HCPCS/CPT® code units conversion.
How can I get ahead of influxes of high-dollar claims for which codes have not been set-up?
  • Fill in gaps related to Unavailable, incomplete, inaccurate or out of date HCPCS/CPT® code level medically covered drug dosing information.
  • Gain real-time access to Missing off-label dosing standards due to incomplete Compendia sourcing.
  • Leverage the most comprehensive crosswalk for HCPCS/CPT and NDC coding either as a reference tool or fully automate claims.
How can I reduce the amount of time that is spent on each high-dollar claim?
  • Fill in gaps related to Unavailable, incomplete, inaccurate or out of date HCPCS/CPT® code level medically covered drug dosing information.
  • Gain real-time access to Missing off-label dosing standards due to incomplete Compendia sourcing.
  • Leverage the most comprehensive crosswalk for HCPCS/CPT and NDC coding either as a reference tool or fully automate claims.
Where can I go for the source of truth related to reimbursement policies?
  • Leverage the industry standard for Current and Historical HCPCS/CPT® (Reimb) Code and NDC Pricing, Drug Detail, Dosing, Diagnosis, Medicaid Rebate and NDC Alignment and Conversion Data for Medically Covered Pharmaceuticals.
  • Realize operational efficiencies through the ability to access (24/7), interact with and manipulate medically covered drug detail, coding crosswalk, pricing, conversion, dosing, and diagnostic data.
How can I eliminate excess drain on my team’s resources due to claims disputes?
  • Appropriate drug administration and diagnostic codes (ICD-CM-10) related to medically covered drug HCPCS/CPT® (Reimb) Codes.
  • Maximum/Minimum dosing and HCPCS/CPT® code unit limits and single dose information to identify overbilling and wastage for high cost / high utilization medically covered drugs.
  • Avoid unavailable, incomplete, inaccurate or out of date data for Administration code data aligned with specific HCPCS/CPT® codes. Enable other departments to access this data directly.
How can I enable my providers to submit claims correctly using NDC codes?
  • Provide your provider network with a direct portal to your reimbursement policies and how to submit claims using correct HCPCS/CPT and NDC crosswalks.
  • Eliminate confusing or unavailable NDC unit and pricing data to be used to convert to and from HCPCS/CPT® codes.
  • 24/7 access to medically covered drug detail, coding, crosswalk, pricing, conversion, dosing, and diagnostic data.
How can I reduce my team’s dependence on our clinical and claims teams?
  • 24/7 access to medically covered drug detail, coding, crosswalk, pricing, conversion, dosing, and diagnostic data
  • Eliminate confusing or unavailable NDC unit and pricing data to be used to convert to and from HCPCS/CPT® codes.
  • Current NDCs and their strength, package details, billing units and conversion factors for active medically covered drug HCPCS/CPT® codes.
How can I reduce our backlog of under/overages?
  • Realize operational efficiencies through the ability to access (24/7), interact with and manipulate medically covered drug detail, coding crosswalk, pricing, conversion, dosing, and diagnostic data.
  • Appropriate drug administration and diagnostic codes (ICD-CM-10) related to medically covered drug HCPCS/CPT® (Reimb) Codes.
  • Effectively manage medically covered drug costs and utilization by limiting coverage to appropriate Administration codes.

Navigator Business Questions

How do I ensure my HIX formulary meets state benchmarks?
  • Highlight where a formulary may be falling short for specific state
  • Embed within your analysts’ workflow
  • Improved operational efficiencies
How can I track my team’s work and stay ahead of potential issues?
  • Increased visibility to who’s making changes with time stamped audit reports
  • Dozens of reports that support each user based on their activities
  • Ensure objectives are hit for specific areas with quality checks along the way
How can I protect myself from CMS validation issues?
  • Reduce formulary risks and improve CMS rates ratings to drive more rebates
  • Automated workflow tool embedded with CMS guidelines
  • Input formulary information and export in a submission-ready format
How can I ensure that all our teams have consistent access to data?
  • Single platform to highlight most recent formulary for all teams
  • Consistently, timely reflection of formulary data
  • Maintain the most up-to-date policy and restriction determinations
How can I close the gap between P&T meetings and member updates?
  • Sync to your searchable website and formulary guides on your website
  • Timely communication of results in proper adjudication
  • Improve member satisfaction through more current updates
How can I keep pharmacy, marketing and IT teams aligned?
  • Access a single source of truth related to drug coverage
  • Communicate updates to internal stakeholders and customer service
  • Reduced technical needs from your IT team
How can we reduce delays between P&T and communication to HCPs?
  • Direct HCPs to updated searchable websites and formulary guides
  • Proper adjudication for an improved prescriber/patient experience
  • Ensure no delays for prescribers to get patient to therapy
How can I be more efficient when flowing formulary documents to clients?
  • Bulk output feature automatically runs behind the scenes
  • Free up your internal team to focus on other priorities
  • Respond rapidly to your clients while meeting production deadlines
How can I simplify the PA process for highly managed drugs?
  • Answer physician’s questions using Formulary Search
  • An all-in-one application for HCPs and office staff to understand UM criteria
  • Provide insights into PA process for drugs requiring PAs or step therapy

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