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Managing pharmacy prescription claims is increasingly complex, with countless variables affecting accuracy, reimbursement and compliance. Invalid NPIs, incorrect dosages and misrouted government-sponsored claims can lead to processing delays, audit risks and financial penalties. Without automated safeguards, pharmacies must dedicate significant resources to manually overseeing clinical and financial factors — diverting attention from patient care.
Pre and post editing services utilize our RelayHealth switch to automatically assess each claim against dozens of parameters, delivering actionable messages that help pharmacies make faster, more informed decisions — optimizing reimbursement and workflow efficiency.
The Enhanced Min/Max edit helps prevent third-party audits, claim rejects and inappropriate payments by validating whether a submitted daily dose aligns with manufacturer recommendations. It compares the quantity and day supply on a claim to the maximum allowable daily dose, helping pharmacies identify potential discrepancies before submission.
The DAW Appropriateness edit helps ensure claims meet payer requirements by validating the Dispense As Written (DAW) code for multi-source brand drugs. If an incorrect DAW is submitted, the edit flags the claim and provides a message recommending a generic substitution or a corrected DAW code, helping pharmacies improve reimbursement and compliance.
