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Payer Solutions:

Tools Designed for Health Plans & Health Systems

Common Business Questions That These Solutions Solve:

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?

Top resources for you:

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 Avoid incomplete, out of date, or incorrect NDC to HCPCS alignment relationships, NDC Level AWP & WAC pricing and additional drug details useful in claim billing and adjudication.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 Fill in gaps related to Unavailable, incomplete, inaccurate or out of date HCPCS/CPT® code level medically covered drug dosing information.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 Fill in gaps related to Unavailable, incomplete, inaccurate or out of date HCPCS/CPT® code level medically covered drug dosing information.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 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 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 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 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
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

Learn More About Our Payer Solutions