Insight
A rejected claim at the pharmacy counter takes a familiar toll: a patient who can't afford the out-of-pocket cost, a pharmacist with limited options and a brand that invested in formulary access watching a therapy start fail.
But there’s a scenario where none of this happens. Where the pharmacist processes the claim, hands over the medication, the patient pays a manageable amount and leaves — and neither is aware the claim was rejected. This isn’t a gap in the system. It’s the system working as a brand designed it to.
Real-time claim conversion — the ability to automatically convert a rejected claim to a paid prescription before the patient or pharmacist sees the denial — represents a strategically underutilized capability in access and affordability, largely because prior authorization has long been the default response to a rejected claim, and for good reason. But PA works best when insurance coverage is achievable, and not every rejected claim presents the same coverage opportunity.
Getting a prior authorization approved establishes coverage that can persist across fills, reduces out-of-pocket costs for patients over time and creates a more sustainable access pathway than a single-fill solution.
But coverage isn't always possible. At launch, before formulary access is established, the likelihood of PA approval can be low. At mid-lifecycle, changing health plan/PBM dynamics can alter coverage odds even for established therapies. And at loss of exclusivity, shifting formulary positions can expose patients to new rejection scenarios. With 73% of providers agreeing that claim denials are increasing,[0]Nguyen, Kelly. Healthcare Claim Denial Statistics: State of Claims Report 2024 the coverage challenge is becoming more consequential across every stage of the lifecycle.
In these situations, a PA process alone doesn't resolve the therapy-start challenge quickly enough — it delays the start while the coverage question is being resolved. A patient whose claim is rejected and enters a PA pathway in a low-coverage scenario may wait days or weeks for a determination. Real-time claim conversion doesn't replace PA in these moments — it works alongside it, allowing therapy to start while the coverage pathway is being pursued.
Brands can configure three distinct pathways: convert immediately at rejection for a defined number of fills; convert and simultaneously initiate a prior authorization to attempt insurance coverage for subsequent fills; or pursue prior authorization first and convert only if denied.
Real-time claim conversion is built for these situations, made possible through a dispensing network of 45,000+ locations — infrastructure embedded at the point of dispense where a rejected claim can be automatically converted to paid, at a cost determined by the brand. No action required by the patient or pharmacist. No awkward conversation at the pharmacy counter. No delay between rejection and resolution.
In a one-year period between 2024 and 2025, this CoverMyMeds solution converted more than 6 million rejected patient claims to paid scripts.[0]Denial Conversion bill data Calendar Year August 2024–July 2025 That scale reflects both the reach of this integrated network and the breadth of scenarios in which brands have found real-time conversion to be the right strategic response.
The brand controls the economics: the price the patient pays at pickup and the number of fills the conversion program covers. This makes real-time conversion a flexible, configurable capability rather than a fixed cost — one that can be calibrated to specific market conditions, patient populations and program budgets. CoverMyMeds' proprietary adjudication platform enables real-time claim visibility across the network, sharing learnings across functions and providing brands with insight into trends, along with program design recommendations to help optimize conversion performance over time.
Coverage gaps don’t always call for the same approach, which is why claim conversion is designed to flex across different strategic scenarios:
Convert at time of rejection for a determined number of fills. For situations where insurance coverage is unlikely in the near term, brands can convert rejected claims immediately and sustain that support across a defined number of fills — keeping patients on therapy while the coverage landscape evolves.
Convert at time of rejection and initiate a prior authorization for subsequent fills. When immediate conversion is the right first response but long-term coverage is still worth pursuing, brands can convert the rejected claim in real time while simultaneously initiating a PA to attempt insurance coverage going forward. The patient starts therapy now. Coverage is pursued in parallel.
Attempt a prior authorization first and convert to paid if denied. For brands that want to exhaust the coverage pathway before activating conversion, this configuration attempts PA first and triggers conversion only if the request is denied — preserving insurance coverage as the primary goal while ensuring the therapy start isn't lost to a final denial.
These configurations give brands the ability to match their response to the reality of the coverage moment rather than applying a single approach to every scenario.
These solutions don't function as disparate programs managed across separate vendors. They're configured and coordinated within CoverMyMeds' connected access ecosystem, where the right intervention activates automatically based on what happens at the point of dispense.
The combination of real-time conversion and PA initiation represents a strong strategic advantage. A patient whose claim is converted to paid starts therapy promptly. The PA initiated alongside that conversion creates a pathway to insurance coverage for future fills — one that includes in-workflow form fill support, intelligent follow-up prompts and, with provider election and patient authorization, direct delivery of the determination notice to patients. If approved, the patient can transition from brand-supported conversion to covered therapy without disruption to access.
Continuity matters for brands because it transforms a coverage gap from a therapy-start crisis into a managed transition. The brand controls the patient's experience across fills, maintains the therapy start and pursues coverage without sacrificing either. This continuity of care is available across 26,000+ dispensing locations in our network — giving brands the reach to sustain this approach at meaningful scale.
Prior authorization support, copay support and real-time claim conversion each address a specific scenario in the access journey. When a claim is rejected and coverage is possible, prior authorization support keeps the brand present through the PA journey. When a claim is approved but cost is a barrier, copay support removes the affordability friction at pickup. And when a claim is rejected and coverage is uncertain, claim conversion keeps the therapy start moving — immediately, invisibly, at brand-determined cost.
What makes this combination more than the sum of its parts is the ecosystem in which it operates. These solutions don't function as disparate programs managed across separate vendors. They're configured and coordinated within CoverMyMeds' connected access ecosystem — a network of 1 million providers, 350+ integrated EHRs, 50,000+ pharmacies, and health plans/PBMs covering 96% of prescription volume — where the right intervention activates automatically based on what happens at the point of dispense.
Access strategies are typically built around the most favorable scenario: with formulary placement secured and PA approved, the patient picks up and starts therapy. Yet coverage gaps are predictable features of the market, and the brands most prepared for them are the ones that have designed an answer in advance — not as a contingency, but as a core element of their strategy.
Real-time claim conversion is that answer. And the design work doesn’t have to start from scratch. Drawing on millions of claims processed annually, our customer success team works alongside brands to evaluate abandonment patterns, rejected claim populations, coverage landscapes and market dynamics — translating that data into program design recommendations that help brands identify where conversion is most needed and configure the right response.
The brands that build this into their approach don't just react to coverage gaps. They close them.
