CMS-Required Outcome
The system adjudicates claims accurately within established parameters. The module can be configured to provide authority/ability to override a reject/edit/denied claim and then resubmit to ensure timely provider claims payments.
- Accurately identifies enrolled providers.
- Pharmacy claims and encounters are priced according to the correct pricing algorithm.
How states write outcomes in this module
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.
The Single Pharmacy Benefit Manager (SPBM) module will improve the accuracy and timeliness of the acquisitions and integration of pharmacy claims encounter data.
The Single Pharmacy Benefit Manager (SPBM) module will reduce the overall benefits and administrative costs of the Ohio Medicaid pharmacy program.