In the marketplace, a conventional belief is that claims processing is a commoditized and low value-added services. In spite of spending significant time and money on legacy claims engines, potential business value is not achieved by the current PBMs. These dated engines have fragmented and inflexible subsystems with multiple incompatible data models — and they need to be replaced. At RxAdvance, we believe claims processing is a core transactional service that has significant potential to be transformed into a high-value and low-cost service.
AdvanceClaims™ delivers this needed transformation to plan sponsors
Low-cost and high-value service is achieved through AdvanceClaims™, an integral component of Collaborative PBM Cloud™, which was built from the ground up using state-of-the-art technology that is highly flexible, scalable, and automated, and that provides and ajudication of specialty and non-specialty claims. This adjudication engine offers unlimited flexibility to design benefits, formularies, pricing, pharmacy network contracts, and compliance changes through rule-based user configurable modules.
Fully integrated system of record for eligibility, membership, prescribers, pharmacy network contracts, pricing, benefits, formularies, authorizations, and compliance rules enabling seamless claims adjudication
Rapid implementation is accomplished through user configurability that leads to dramatic improvement in timeliness, cost, and accuracy
Fully integrated and highly flexible Formulary Management Services (AdvanceFormulary™), a core component of AdvanceClaims™. Highly customizable to a payer’s membership and line of business. Facilitates proactive formulary modeling to optimize clinical and financial outcomes
At Point of Care when an eligibility/benefit/authorization /formulary request is generated, IntelligentDUR360°Gateway™ instantaneously aggregates actionable information from multiple components of Collaborative PBM Cloud™ and delivers this information into the physician’s workflow as a single message
At Point of Sale when pharmacy claims are submitted for adjudication, IntelligentDUR360°Gateway™ instantaneously aggregates actionable information from multiple components of Collaborative PBM Cloud™ and delivers this information into the pharmacist’s workflow as a single message
Proactive member engagement is initiated when patient-specific quality/cost information is generated in Collaborative PBM Cloud™ and is then delivered to the member’s smart mobile device using IntelligentDUR360°Gateway™
Clinical/pharmacy staff of plan sponsor are engaged collaboratively through Patient-Rx360°™ to reduce pharmacy costs and drug-impacted medical costs, and improve health outcomes