In our February 2023 Newsline article, PBM Prescription Validation Requests Rose Nearly 20% in 2022, we mentioned that while the validation requests are a nuisance, they can work to the pharmacy’s benefit. Because the PBM is looking at the claim before payment is received, pharmacies can avoid incorrectly refilling a medication if an error is detected and potentially correct a billing error on the date that it is being reviewed. This can prevent large financial recoupments upon a future audit. These requests can also be very frustrating when the claim reviews are repetitious, and no billing errors are found creating work for the pharmacy without any need to correct the claim. See the PAAS tips below for best practices on how to track and manage duplicate or high numbers of validation requests.
- Have a designated individual manage the validation requests
- Keep a binder or folder to track of all requests from month to month
- PAAS often sees duplicate validation requests from members on claims that have already been validated
- If there is a claim that has already been validated with no issues, pharmacy should push back and ask the PBM (or contracting entity) to stop sending requests every month
- OptumRx/EXL makes up the vast majority of the pre-pay reviews that members report to PAAS. If you feel you are getting a large number of requests from OptumRx, politely push back on this as well
- If your pharmacy receives “results” from EXL for an OptumRx validation request, typically no action is required by the pharmacy at that time. OptumRx will review the electronic claims data and send the pharmacy a letter if they found an error on the claim.
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