Rejected Claims / Fraud, Waste and Abuse


Our Rejected Claims Product is designed to assist Part D sponsors with oversight of claims processing coding above and beyond any reporting tool plan sponsors may be receiving from their PBM to ensure:

  • Claims are adjudicating according to the CMS-submitted and approved formulary, including UM edits, B vs. D determinations and CMS exclusions. CMS expects that Part D sponsors have regular / ongoing quality checks in place throughout the plan year to maintain proper oversight of the PBM subcontractor (refer to 42 CFR 423.505)
  • Compliance with 42 CFR § 423.120 (b)(3), which states a Part D sponsor must provide an appropriate transition process for new enrollees, and in some cases current enrollees who are prescribed Part D drugs that are not on the Part D sponsor’s formulary. CMS requires that Part D sponsors provide documentation that their transition policy is correctly implemented in their claims system and that beneficiaries are receiving their required transition supplies.

Problem: Issues for Part D Sponsors

Part D Sponsors need an efficient way to monitor the volume of rejected claims and PBM coding with limited staff:

SBG’s Formulary Administration Oversight Solution

  • Assure logic of the programming for all drugs that changed formulary status from one year to the next to ensure they adjudicate properly.
  • Assure claims for formulary drugs do not reject for inappropriate edits such as MADD limits under the FDA stated maximum.
  • Assure transition logic prior to the start and throughout the plan year to ensure that claims for new beneficiaries will not reject when transition supplies should be provided.
  • Perform quality checks by routinely comparing the formulary file submitted to CMS and the adjudication system file to ensure that there are not inconsistencies that could create discrepancies and inappropriate rejections (e.g., unapproved UM, drug deletion, etc.). This is essential not only at the beginning of the plan year but also throughout the plan year as formulary modifications occur.
  • Complete a review of 100% of rejected claims to identify and correct any formulary and transition errors and then periodically review rejected claims to ensure no new errors develop.

Value to Part D Sponsors:

The Rejected Claim Analysis product provides plan sponsors with reports that simplify the process of monitoring rejected claims by eliminating false positives which are rejecting properly. This sophisticated application analyzes the claim data using the plan’s formulary, benefit design and utilization management criteria and produces actionable reports that are easy to understand.

The report isolates rejected claims that may require additional follow up with the PBM. This enables you to:

  • Effectively monitor your PBM’s performance in claims processing.
  • Demonstrate your plan’s compliance with CMS regulations.
  • Ensure your beneficiaries are receiving the plan benefits to which they are entitled.
  • Initiate a corrective action plan in a timely manner if the rejects are due to a coding error.
  • Document your oversight of the PBM claims processing.

The analysis of rejected claims will use sponsor specific drug lists such as:

  • B v D
  • Unbreakable package
  • Part D excluded medications
  • Part D covered vs. excluded
  • Protected class medications and specific look back period
  • ESRD/Hospice covered medications

The analysis of rejected claims will also use sponsor specific error codes and messaging along with the standard NCPDP error codes and messaging. These rejected claims will be grouped by reject type into workable files for the Part D sponsor.

During the implementation of our Rejected Claim Analysis product the Part D sponsor will have an SBG pharmacist to assist in information/file transfer as well as step by step instruction on how to get the most from these reports.

Fraud, Waste and Abuse

We will review and evaluate your current FWA program and your PBM’s program to ensure you are in compliance with current federal and state regulations.
The thorough FWA review by Certified Fraud Examiners, SBG will evaluate the following in order to confirm compliance, identify gaps and work collaboratively on remediation:

  • Analytics
  • Timeliness
  • Reporting requirements
  • Documentation
  • Investigation process
  • Support PBM review and meetings

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