Business Analytics

Claim Level Reconciliation

ClaimPay posts opens account receivable claim level data from their software vendor or from your pharmacy switch vendor. Once posted your claims data is reviewed for accuracy and completeness. Payment data detail is received, processed, and matched at the claim level (including RX number, fill date and other data elements to insure a unique one-to-one match occurs). This claim level reconciliation is how we identify underpayments, overpayments, non-compliance with contract terms/rates, provide necessary feedback to the PBM’s, and remedy any non-compliance issues.

Additionally, we utilize payment forecasting tools to know when payments are anticipated and whether or not they are compliant with contracted terms.

  • On a weekly basis, ClaimPay imports and posts claims as an open item accounts receivable, for all of your claim data from your PBMs Insurance Plans and third party plans, and we verify and validate the data for accuracy and completeness
  • Post Payments received from the PBM’s, Insurance Plans and other third party payers
  • Conduct a one-to-one open item claim receivable matching process with the corresponding unique payment detail records.
  • Research and follow up on all outstanding claims
  • Archive all reconciliation data
  • Research and follow up on all rejected and denied payments
  • Research and follow up on all unmatched and underpaid claims (Suspense & Exceptions)
  • Provide a monthly summary aging of all unpaid claims by payer