Claims Manager Plus: Helping 340B Pharmacies Smooth Out the Bumps

Running a 340B pharmacy is a complicated business, especially considering the varying requirements from payers that can wreak havoc on your bottom line. That’s why Sentry continually works to develop new tools and services to help you stay on top of things and keep your reimbursements moving.

Claims Manager Plus (CMP) is our solution; an automated software solution that helps users adhere to payer requirements, minimize denials, and speed up processing pharmacy claims by almost any payer, or for carving in or out 340B. It’s also indispensable in helping manage complex, government-mandated reporting requirements.

Claims Manager Plus helps you correct errors on claims and adhere to other requirements by flagging items such as:

  • Missing modifiers and prices
  • Purchase validation of NDCs billed
  • Unspecified destination payer codes
  • Incorrect NDC codes
  • Drug quantity and unit of measure validation
  • NDCs not matched to HCPCS codes
  • Crossover modifiers between payers

The tool automatically modifies claims based on the configurations you establish. It flags errors and rejections and can re-validate them based on edits you make directly in the application.

Best yet, CMP uses machine learning, so changes you make are incorporated into future claims, automatically adjusting the information with no need for manual intervention. These auto-corrections continually decrease the percentage of claims that get rejected as time goes on.

A boon to users

The ability to make edits directly in the platform was especially attractive to a pharmacy regulatory analyst who manages 340B programs for more than 25 covered entities. Before implementing CMP, she coordinated edits with central billing whenever there were mistakes and then resubmitted the claims.

Now, Claims Manager Plus manages that work for her. “CMP has saved us hundreds of thousands of dollars in man hours and allowed our staff to do other things that are much more important for both the hospital and our 340B program. For me to have freed up so much of my time to work on compliance in the hospital, is really invaluable,” she shared.

For a 340B program coordinator at a California-based health system, CMP was a huge help in meeting the state’s Medi-Cal (Medicaid) program rules.

The program coordinator had previously been buried by the demands of matching miscellaneous HCPCS codes for processing Medicare and Medicaid claims to NDC codes for 340B reporting, plus adding modifiers to meet Medi-Cal requirements.

Manually auditing so many claims “consumed my days, and some nights,” she recalled. “Today, I probably have to edit fewer than a dozen clients per site, per day.”

Claims Manager Plus ultimately allows users to directly edit NDC codes, modifiers, and prices on demand in the application, and then incorporates those changes into the rules engine so they don’t have to be repeated. CMP also compares specific NDCs to invoices to ensure a match or find the correct NDC, dropping any unmatched claims into a queue for review.

Learn more about how CMP can streamline your claims management by visiting our website!

Jami Hernandez is Senior Product Manager at Sentry Data Systems.  She can be reached at jamihernandez@sentryds.com.

To read the 340B Report Spotlight on Sentry’s Director of 340B Compliance & Audits, Ivy Espendez, click here.

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