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

Continue reading in part 2:

RJ Health’s Medical Drug Edits apply industry leading drug data and algorithms to validate customer claims


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.