What does it take to get a paid claim for a prescription?
Ask any pharmacy billing specialist and they can tell you exactly how to do it. Pharmacy billing claims use the NCPDP Telecommunications Standard D.0 claim format, a code system that communicates prescription claim data to third party payers.

Submitted claims are adjudicated almost immediately, informing the pharmacy whether the claim is approved or denied.

Medical claims are distinctly different and more complex. Medical claims require a larger data set and are not adjudicated immediately, sometimes taking weeks to receive an approval or rejection. Creating a claim to a medical payer cannot be directly accomplished using a standard pharmacy operating system. To submit medical claims today, pharmacies must either submit a paper CMS-1500 claim form, or employ an entity known as a clearinghouse to translate the claim from NCPDP D.0 to ANSI-X12 837, the standard format used to send health care claims electronically.  

By partnering with a clearinghouse, pharmacies can create and submit medical claims using the existing prescription billing pathway. Claims data is sent to the clearinghouse in NCPDP D.0 format. The clearinghouse then translates the data to the appropriate corresponding medical claim format for submission to the payer.   Many clearinghouses provide insight into the claims process along the way, notifying the pharmacy of approval or rejection, or if additional information is needed.

Clearinghouses also provide an opportunity for additional revenue streams and expanded service offerings, creating a clear pathway for reimbursement for service-based activities, such as vaccine administrations, MTM services, or e-Care plans. Additionally, clearinghouses can be used to bill Medicare Part B for things like medical equipment (DME), supplies (ostomy, wound care, etc.), and other items not otherwise covered by a prescription drug benefit plan.

As the profession of pharmacy evolves, and the scope of practice continues to expand, pharmacies increasingly need to bill for products and services using medical claim formats.   Having a clearinghouse partnership can support this complex need in a simplified and streamlined manner. For more information on clearinghouses, check out this helpful article, or reach out to the SoftWriters team.