Express Scripts Validating 340B Claim Eligibility
PAAS continues to see members receiving emails from Express Scripts (ESI) requesting pharmacies to “Please Review Your 340B Eligible Claims”. ESI’s goal is to verify manufacturer rebate eligibility and states “your claims reimbursement, network participation, and network status are not affected by a claim’s status as 340B-eligible or whether you respond”.
While seemingly haphazard in claim selection and frequency, Express Scripts is attempting to identify a subset of claim(s) that were initially processed as not 340B-eligible, but in actuality may have been dispensed/reimbursed as 340B. From communication with members, PAAS can see the algorithm ESI is using is far from perfect. Conjecture leads us to believe they are using the HRSA OPAIS website to look at providers and pharmacies, then targeting high dollar brand medications.
If the pharmacy agrees that the claims were 340B claims, no action is required and Express Scripts will reprocess the claim(s). If the pharmacy believes the claims were correctly adjudicated as non-340B eligible, the pharmacy should respond within 10 business days by emailing firstname.lastname@example.org to refute Express Script’s conclusion.
- View PAAS’ webinar 340B Contract Pharmacy Considerations for 2021, which was based on ESI’s 340B Provider Manual changes
- If your pharmacy is a 340B contracted pharmacy, follow up with your 340B administrator to ensure you have access to claims level detail
- If the claim did not meet 340B criteria (e.g., ineligible provider, patient, or Medicaid eligibility) be sure to refute ESI’s findings with documentation
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