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Pharmacy Claim Advisor

Comprehensive Claims Management
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Improve state Medicaid program outcomes.


Pharmacy Claim Advisor provides real-time claims adjudication, management, and services for state Medicaid programs. Comprehensive capabilities include prior authorization workflow (electronic and manual), drug reference data and rules management, retrospective drug utilization review, SMAC workflow, web-based portal, helpdesk call management, and reporting. NCPDP and HIPAA-compliant pharmacy claims are transmitted to the processor, where client-specific rules and criteria can be applied. Automating these processes maximizes efficiency and drives cost savings.


  • 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.

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  • Prior Authorization

    Change Healthcare Prior Authorization is a workflow tool that efficiently generates approval and denial responses at the conclusion of the prior authorization decision process. Each PA is assigned a unique ID for ease of maintenance updates, changes and tracking purposes. Electronic prior authorization is an automated rules-based claims module that determines if claims can process or needs manual authorization and clinical review.

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  • Drug Reference

    Change Healthcare drug formulary tools reports new National Drug Codes included in each week’s drug file and addresses new NDCs with timely recommendations. We monitor both the MediSpan and First DataBank drug reference files for new drug products on a weekly basis as needed.

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  • SMAC

    Change Healthcare SMAC solution assists the State in establishing SMAC rates using CMS approved methodology. Through our tool, the rate is applied to both brand and generic drug products in each drug group. Proven for over a decade, this process saves millions through effective drug pricing.

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  • Drug Utilization Review

    Change Healthcare DUR system utilizes claims history, provider and reference data to assist in the DUR function. This provides all required notifications to providers in a timely manner, allowing providers to adequately counsel clients regarding potential problems associated with their prescription. It accepts and employs only criteria specifically approved by the Department for ProDUR activities and can easily accommodate changes in those criteria.

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