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Claims Management

Change Healthcare Pharmacy Claims Management application is a flexible rules-based claims adjudication engine. At the point of sale, claims are automatically approved or denied based on member eligibility, drug rules and prior authorization criteria. These rules and specifications are fully configurable to match business and clinical rules established by state and federal policies.

Adjudicate and manage pharmacy claims real-time.

Adjudicate Claims In Real-Time

The Pharmacy Claims Management tool provides real-time claims adjudication and management. Pre-defined edits and authorization criteria are applied during the claims adjudication process with a full record maintained in the system.


Automate Processes

Automated processes allow for efficient workflow, cost savings and faster claim processing. The use of an integrated electronic prior authorization process applies algorithms on claims to avoid denials when applicable.


Ensure Regulatory Compliance

Configured to meet individual state requirements as well as client needs, Pharmacy Claims Management ensures strict regulatory compliance with NCPDP and HIPAA. Preferred Drug List and formulary rules provide control of dispensing under Federal and State policies.