How are claims screened and what does “transparently screened” mean?
Virtually all pharmacy claims are processed online-real time. The claims are juried against other drug claims, participant diagnoses, and prior participant procedure claims. Clinical rules (edits) are established that look for those data elements, thus eliminating many calls for providers. Claims meeting approval criteria require no call and occur over seventy-five percent of the time. Claims not meeting criteria are rejected and must be overridden by the call center if necessary.
