Pharmacy Billing

Pharmacy billing is not medical billing with different drug names. Claims go out as NCPDP transactions through a PBM switch and come back in seconds, priced against a formulary that changes without notice. Margin is lost in small amounts on thousands of fills: a reversal never re-billed, a DIR fee absorbed as a write-off, a 340B claim that should have been split. We work the rejects while the patient is still at the counter, reconcile every fill against what the plan actually paid, and keep the documentation an audit asks for before it asks.

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What we handle

NCPDP D.0 claim submission through your switch, with rejects worked at the point of sale rather than queued for later
Eligibility and formulary checks before the fill, so a plan limitation is caught while the patient is still at the counter
Prior authorisation handling for specialty and non-preferred drugs, tracked to a decision
Drug utilisation review exceptions reviewed and documented, not blind-overridden
Reversals, re-bills and partial fills reconciled against what the plan actually paid
Remittance posting from 835s and PBM statements, with DIR fees and clawbacks identified separately
Copay, coinsurance and deductible amounts explained to patients in writing
Compounded prescription billing with per-ingredient pricing support
340B eligibility, split-billing and duplicate-discount reporting
Audit response packs assembled for PBM desk and on-site audits

Medicare Part B and Part D billing

Pharmacies also bill Medicare for vaccines, covered drugs and clinical services. We prepare, submit and follow up those claims so eligible services get paid.

Medicare Part B

Covered vaccines and their administration, plus Part B drugs, biologicals and injectables, billed as medical claims with CPT and HCPCS coding and NDC-to-HCPCS crosswalks.

Medicare Part D

Prescription and vaccine claims to Part D plans, with plan identification, rejection troubleshooting, prior authorisation, coordination of benefits and rebills.

Part B or Part D vaccines

Each vaccine goes to the right benefit. Influenza, pneumococcal, COVID-19 and hepatitis B go to Part B; most other ACIP-recommended adult vaccines go to Part D, generally at no cost to the patient.

Medication therapy management

MTM sessions documented and billed with CPT 99605, 99606 and 99607 where the payer covers them.

Medicare eligibility verified before the service
Rejected and denied claims worked and resubmitted as corrected claims
Payments posted and reconciled, with accounts receivable followed up until closed

Coding always follows the service provided, the documentation, and each payer's policy.

Pharmacy systems we work in

We bill inside the pharmacy management system you already run, so your staff keep their workflow.

PioneerRxCommunity Pharmacy Management System
BestRxCommunity Pharmacy Management System
PrimeRxCommunity Pharmacy Management System
Axys LTCCloud-Based LTC Pharmacy Management System
NRxCommunity Pharmacy Management System
PrimeCareLong-Term Care Pharmacy Management System