SPONSORED CONTENT
In today’s 340B environment, every claim counts. With increased oversight, tighter margins, and growing manufacturer restrictions, covered entities need to maximize their 340B savings by capturing every eligible claim. One often-overlooked opportunity lies in understanding and monitoring disqualified claims.
These are claims that, for one reason or another, didn’t qualify for 340B qualification—but could have. Rather than accepting disqualifications at face value, covered entities should treat these claims as signals for action. Below is a guide to reviewing and correcting disqualified claims, in collaboration with your third-party administrator (TPA), to ensure you aren’t leaving savings on the table.
Start by Working with Your TPA
Your TPA plays a critical role in filtering and qualifying claims for 340B eligibility, and their system often holds valuable insight into why claims are being disqualified. Start by requesting a disqualified claims report from your TPA – not all TPAs provide this proactively.
Having this visibility gives your team the opportunity to dig deeper and identify patterns or errors that can be corrected moving forward.
Key Areas to Review in Disqualified Claims
Once you have the disqualified claims report in hand, focus on the following categories
1. Pricing Fall-Offs
Sometimes a claim qualifies clinically but is disqualified due to pricing data not being available or applied correctly. This can occur if 340B pricing is delayed or not loaded.
Work with your TPA and wholesaler to determine why pricing was missing and whether those claims can be retroactively captured or reprocessed.
2. Eligibility Window Issues
Your 340B program eligibility depends heavily on encounter data and timing. Many disqualified claims stem from:
- Providers who are 340B-eligible but whose encounters fall outside your configured eligibility window
- Missing or delayed eligibility files
Solutions to consider:
- Expand the eligibility window to capture a broader range of legitimate encounters
- Audit your eligibility files and submission process to ensure complete and timely data
Even small configuration changes here can have a major impact on claims capture.
3. Medicaid Mismatches
Medicaid carve-in/carve-out status can be a common source of disqualification—especially if payor information isn’t clearly defined. Disqualified Medicaid claims may happen if:
- The claim is incorrectly flagged as Medicaid, when it’s a Medicare or a Commercial plan
- You don’t have the correct BIN/PCN or Group ID listed in your TPA configuration
- Payors are not properly mapped or blocked/unblocked in the system
Take time to confirm your payor list and cross-reference it with what the TPA sees. Ensure all “should-be-qualified” payors are being handled correctly.
4. Data Feed or Switch Issues
In some cases, the problem isn’t qualification logic—it’s data availability. If your TPA isn’t receiving a complete or accurate feed of your claims data, disqualification can happen simply due to missing context.
Things to watch for:
- A sudden drop in 340B-eligible volume that doesn’t align with patient or script trends
- Claims from certain providers or locations missing consistently
- Switch issues that prevent prescription information from being transmitted
If these patterns emerge, engage with your pharmacy, switch vendor, or EMR to ensure full data is being transmitted.
Make It a Routine Process
Disqualified claims review shouldn’t be a one-time effort. It should be part of your monthly or quarterly monitoring process. A regular review process can help you:
- Identify technical or systemic issues early
- Adjust configurations as your program evolves
- Improve your 340B capture rate steadily over time
Final Thoughts
340B compliance will always be critical—but optimization is equally important. Disqualified claims represent real dollars and missed opportunities. By partnering with your TPA, auditing your program setup, and being proactive with your data, you can recover those claims—and more importantly, prevent future losses.
Remember, in today’s 340B world, every claim matters. Don’t let yours slip through the cracks.
Samantha Mantuano is Vice President of Program Management Operations at Pillr Health. She can be reached at smantuano@pillrhealth.com.
