Prescription Claims Processing:

MedOne Healthcare Systems provides a comprehensive real-time, on-line claim processing, adjudication and reporting system. Upon entering a participating pharmacy, the covered member presents their ID card along with a valid prescription. The pharmacy enters the data into their computer system and the claim is transmitted to our host computer.

Claims submitted online, at the point-of-sale are instantly adjudicated using over 500 system edits including verification of benefit design restrictions, and eligibility status. This data is used to approve or reject claims online at the point-of-sale, as well as to adjudicate submitted paper claims. If the claim passes the edit process, the system determines the co-pay based on the Client’s plan-specific edits, and the claim is approved.

If the claim does not pass the edit process, corresponding information or a rejection message is returned to the pharmacy explaining the edit failure. Examples of return messages for rejected claims include “plan limitations exceeded” “drug not in formulary,” “non-matched cardholder ID,” “duplicate claim,” or “drug interaction.” MedOne Healthcare Systems also has the ability to customize a free-text message to the pharmacy based on the client’s requirements. Regardless of which pharmacy a member uses, all of the information is processed through the MedOne Healthcare system. This not only protects the member, it also prevents fraud and possible medication abuse.

Customized Client Services:

MedOne Healthcare Systems is committed to the highest possible levels of client service.
Our program includes:

• A step-by-step comprehensive implementation process
• A dedicated account representative is assigned to each client
• Full service help desk with toll-free number and extended coverage hours
• Extensive network that includes 59,000 pharmacies nationwide, both chain and independent (see pharmacy locator)
• Drug Utilization Review – concurrent and retrospective
• Clinical services and wellness programs designed to address client needs
• Extensive plan reporting capability
• Comprehensive auditing and fraud detection program
• Quarterly plan reviews with a MedOne Healthcare Systems representative - including recommendations for plan benefit changes
• Flexible plan design options

MedOne Healthcare Systems’ program offers extensive flexibility in terms of the design of the plan benefits. Co-payments may be percentages or fixed dollar amounts. Two tier or three tier co-pay designs are available. Days’ supply limitations are available, as well as up front deductibles, annual maximums, and inclusion of mail service and specific benefit limitations.

MedOne Healthcare Systems maintains a therapeutic formulary for client use. However, with our flexibility, the client’s specific needs and requests can usually be met concerning benefit design and formulary management.

MedOne Healthcare Systems is a full service prescription benefit management company, providing the latest in pharmacy benefit management technology while also providing excellent local client and customer service.

Please contact us today!