RxAdvance’s guiding principles include interpreting the CMS/state/plan sponsor-specific compliance guidelines, building consensus between plan sponsors and RxAdvance, and configuring the Collaborative PBM Cloud™
to achieve the highest possible degree of compliance automation with minimal personnel involvement.
Overarching line of business guidelines: RxAdvance’s Collaborative PBM Cloud™ comes with built-in library of federal and state compliance guidelines that were interpreted and configured into the system so that compliance is accomplished both at transactional and operational levels.
Plan sponsor benefit design guidelines: As part of onboarding a plan sponsor, RxAdvance SME’s evaluate, interpret, and configure plan sponsor benefit design guidelines. Leveraging Collaborative PBM Cloud™, RxAdvance brings transparency to plan sponsors by seamlessly sharing the interpreted configuration. Upon approval by the plan sponsor, RxAdvance promotes the configuration to production.
Ongoing regulatory compliance changes: RxAdvance SMEs provide up-to-date responses to federal guidance and new and pending legislation. RxAdvance is part of a compliance coalition team that participates in weekly user calls and industry conferences and monitors the direction of federal programs.
PBM Service Level Agreement (SLA) Compliance: Collaborative PBM Cloud™ enables RxAdvance to configure all elements of plan, sponsor-specific ALAs, providing service delivery staff with tools and workflow triggers to meet SLA requirements. Through AdvanceESM™, RxAdvance provides service managers and plan sponsor supervisors full and complete access to real-time service level activity.
Leveraging AI driven algorithms, Collaborative PBM Cloud™ continuously monitors preset service delivery thresholds which are configured during onboarding of a plan sponsor. This monitoring process proactively auto-triggers changes to service delivery resources including activation of third party overflow vendors to fulfill all agreed upon service levels. Proposed benefit design changes, (e.g. formulary/prior authorization modifications) can be modeled to promote effective service delivery management.
Audit Support: RxAdvance believes in giving full transparency to the plan sponsor regarding all PBM-related activity, eliminating the need for onsite plan sponsor audits. When it comes to regulatory agency audits, RxAdvance provides full access to the “auditor role” using role-based security. Through this role, the auditor is able to inspect the system-configuration rules, simulate a transaction, and validate the outcome. In addition, the system provides complete access to all member-level transactional information.
The table below illustrates a representative set of compliance requirements that are automated through Collaborative PBM Cloud™