RJ Health’s Medical Drug Edits: Industry leading drug data, algorithms to validate drug claims

In Medical Drug Edit Blog Post #1, we saw that pre-payment edits of Medical Drug claims can be utilized to improve claim submission and reimbursement accuracy.  Payors and providers license RJ Health’s Medical Drug Edits and access them via our API platform.

This is because effective pre-payment review of medical drug claims requires:

•  The ability to obtain, store and maintain or to access comprehensive and up-to-date drug data

•  The development and continued maintenance of claim edit logic as policy and trends change

•  The ability to apply claim edits to medical drug, organizational data and claim data

•  Expert clinical, business and IT resources

In addition, the resulting claim edit function should:

•  Utilize correct and comprehensive medical drug detail, coding, pricing and clinical data

•  Verify the submitted claim data against the medical drug data

•  Integrate stored organizational policy, formulary, and fee schedule data

•  Apply logic to verify/provide/correct values or flag errors and produce reason codes

•  Return results for correction, adjudication, denial or communication

•  Produce reportable outcome data

In fact, well-designed Medical Drug Edits can improve claim operations and payment accuracy by:

•   Ensuring appropriate price methodology application

•   Driving adherence to reimbursement policies

•   Identifying network compliance and quality opportunities

•   Delivering content for claim related communications

•   Providing insight to prior authorization compliance

We would love to share what we have learned from our experience helping customers automate their Medical Drug reimbursement processes.


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.