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5 Essential Features Required for Pharmacy Claims Adjudication in 2021 and Beyond

Health plan cost increases and projections for 2021 continue to outpace general inflation and average wage increases significantly. Health insurers, Pharmacy Benefit Managers (PBMs), and other plan administrators hoping to avoid potential cost shifting will require sophisticated tools and innovative strategies. These requirements are especially true for pharmacy benefit managers. A claims adjudication platform designed to streamline claims processes, provide custom benefit solutions, and increase transaction efficiencies will be essential to targeting problem claim areas -- without reducing the value of the plan for participants.

Recently, Segal, a leading employee benefits consulting firm, released its 2021 Health Plan Cost Trend Survey. While last year’s survey reported a slowdown in medical trend projections, one key finding from 2021 is that medical plan costs will continue to rise.

Other key findings include:

  • The trend for outpatient prescription drugs is expected to be 7.3 percent for 2021.

  • Double-digit specialty Rx cost trend, mostly driven by price increases and new specialty drugs, continues to be a challenge for plan sponsors.

  • The current public health crisis has made understanding claims data and the factors influencing benefit costs even more vital.

Now, more than ever, pharmacy claims play a critical role in the health insurance business. Meeting the challenges ahead brought by the pandemic, drug cost increases, legislation focused on pharmacy rebate programs, and other disruptive market events will require powerful claims adjudication platforms.

Benefit Managers (PBMS), health insurers, and others must select a platform that delivers outstanding customer experience while improving pharmacy cost-savings, benefit plan management, and trend predictability. When evaluating PBM claims adjudication software solutions, insist on the following five essential features.

1. Cloud and web-based technologies for optimal business growth

To deliver benefit management solutions quickly, securely, and reliably invest in the latest cloud and web-based technologies. You gain flexible infrastructures allowing easy benefit modifications, instant feedback, access to files and documents through a shared platform, expanded data storage, API-driven tools for immediate decision-making, advanced network configurations, and unlimited server capacity for scalability.

2. Advanced security to meet healthcare privacy regulations

The platform must safeguard patient data and ideally surpass the demands of today’s healthcare regulatory environment.

• Certified SOC3, ISO27k, SOX, and PCI-compliant data centers

• Federated authentication security with OAuth 2.0 and OpenID Connect

• HIPAA and regulatory compliant

3. Ease of implementation and customization to save time and resources

Your claims processing platform will need to meet current and future benefit configurations. It should allow for easy implementation by reducing the complexity during migration to save time, resources, and set-up costs. Customizable features allow you to improve both financial and satisfaction outcomes while increasing productivity. Discover if you are able to add unique claims rules, rebate accumulators, and other claims parameters. Look for self-serve member tools that easily can be integrated into your current system to meet healthcare’s diverse regulatory requirements and operational processes.

4. Intuitive design to meet unique and evolving industry needs

Today, many companies working with the software-as-a-service (SaaS) platforms know the importance of good design. An intuitive platform design with easy navigation will assist pharmacy benefit managers in meeting unique needs and evolving business objectives.

Just because a product is designed to look and feel beautiful doesn’t mean it’s useable. Great design balances an excellent user experience (UX) with an interactive user interface (UI) to create the best overall results. All too often, product build focuses exclusively on the look and feel instead of placing equal emphasis on intuitive and responsive usability features.

Be wary of claims platforms built by organizations unfamiliar with the health insurance industry’s distinct challenges and nuances. They may deliver solutions that are unfocused or too broad to meet your needs. By contrast, a platform built by health and technology industry experts will be sure to focus on putting pharmacy claims handlers at the center of product design. Be sure the platform design and features can be configured to overcome the barriers faced by your business and will allow for leading-edge product enhancements.

5. Real-time data and transparency for actionable insights and targeted interventions

Don’t rely on antiquated claims processing engines. The best software will use smart processes that eliminate wasted time and resources. Real-time access and expanded visibility into benefit configuration and claims transactions help solve the immediate and ongoing problems associated with delivering pharmacy savings and predictable results. You’ll be able to generate reports, monitor performance, and evaluate a claim’s progress to identify immediate and targeted interventions at the earliest opportunity.

Ask For a Demo Today!

CONTACT: Paige Zimmer @ for additional information on the RxLogic Claims Adjudication Platform.

Paige Zimmer is Executive Vice President, Business Development at RxLogic. She has over 25 years of experience in building best in class client relationships and producing significant business results in the healthcare industry. Paige’s experience includes managing sales, marketing, business

development and client service teams for health plans, pharmacies and PBMS’s. Within pharmacy technology and software as a service, she has led custom and traditional claims processing needs for employers, government programs, pharmacies and health plans. Paige has held

executive/management roles at organizations including HealthPartners, Eli Lilly, MedImpact, and ScriptSave.

5 Essential Features Required for Pharma
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