PBM1
CMS-Required Outcome
CMS-required outcome
The system adjudicates claims within established time parameters to ensure timely pharmacy claims payments.
Default metrics
- Timely adjudication of pharmacy claims and encounters.
- Percentage of claims paid on time (only if payment is included in RX module)
- N/A if payments are issued from the MMIS system.
Regulatory sources
- Section 1927(h) of the SSA
- 42 CFR 456.722 - POS requirement to support claims adjudication or payment
How states write outcomes in this module
OHTo support the implementation of a more efficient and cost effectivfe operating model to deliver pharmacy benefits to Ohio Medicaid members.
The Single Pharmacy Benefit Manager (SPBM) module will provide accurate and timely processing of pharmacy claims utilizing fully transparent pricing and payment methodologies as determined by the Ohio Department of Medicaid.
OHTo support the implementation of a more efficient and cost effectivfe operating model to deliver pharmacy benefits to Ohio Medicaid members.
The Single Pharmacy Benefit Manager (SPBM) module will improve the accuracy and timeliness of the acquisitions and integration of pharmacy claims encounter data.
OHTo support the implementation of a more efficient and cost effectivfe operating model to deliver pharmacy benefits to Ohio Medicaid members.
The Single Pharmacy Benefit Manager (SPBM) module will reduce the overall benefits and administrative costs of the Ohio Medicaid pharmacy program.