Claim ‘washing’

The Production Pharmacist Assistants, as part of their Production Process Flow are responsible for managing the exception reports as per the claim responses received from the PBM ie Partially Approved or Rejected Scripts, in order to get a claim to the approved status, by doing the following:

Partially Approved Scripts:

  • The “Early Fills” are being re-scheduled to ensure that the claim date is aligned with the 28 day chronic cycle;
  • The “Co-pays as per Scheme Rules” are communicated to the patient and lawful substitution is proposed if and where possible to reduce the quantum and the financial burden of the co-payment on the patient.

 Co-payment collections

  • Scheme enforced co-payments are collected at the point of collection in the case of an AlphaScript Network Provider providing the service; or
  • In the case where AlphaDirect have delivered the medicine to the patient’s home or workplace it is recovered by means of:
  • Authorized by means of a duly signed Debit Order Authorization Form by the member for him/her and his/her dependents if applicable.
  • Note: Co-payments less than R20 per patient will be written off by AlphaScript; or

Rejected Scripts

  • Membership suspended and or funds depleted are communicated to the member and alternative methods of payment by the member is explored failing which a patient note is made and the claim reversed and cancelled;
  • Authorization required will result in a script being forwarded to the AlphaScript pre-authorization department from where the pre-authorization process as described herein will be initiated.