Our Heart is in Public Health

Claims Processing and Management

Ramsell Public Health Rx provides electronic claim adjudication services can be designed to meet individual program dispensing guidelines and plan rules or limitations.

These plan rules include, but are not limited to:

• Formulary drug coverage
• Prior authorization requirements
• Dispensing controls and limitations

For claims requiring manual entry, our proprietary data management system, PMDC Systems™, provides a manual claim function through a secure Internet website.

Additionally, PMDC Systems™ offers a series of quality assessment reports used to verify the proper payment of claims.

Pharmacy Network Development and Management

Tailoring a pharmacy network to meet the needs of each individual program is the key to making the programs truly accessible to patients. This involves geograhically mapping service areas and selecting pharmacies that fulfil critical categories.

Chain and independent pharmacies, mail-order pharmacies, institutional pharmacies, jail pharmacy systems, and specialty pharmacies - such as home infusion, compounding and HIV - are all vital to program success.

Formulary Management

Program sponsors have the flexibility to design a number of different formulary coverage levels. Using First DataBank’s National Drug Data File also helps with price management, and assures delivery of the best clinical information.

Formulary management services include, but are not limited to:

• Development of drug dispensing policies
• Formulary-based claim adjudication controls and formulary lists
• Consultation services of pharmacists and staff experienced in formulary design

When designing a formulary, Ramsell Public Health Rx takes into consideration standards of care, cost containment, enforceability of limitations, and fraud prevention.

Clinical Services and Drug Utilization Review

Ramsell Public Health Rx’s flexible clinical services group is experienced at managing proven cost-effective programs and for managing utilization protocols. We work closely with our clients to establish clinical guidelines appropriate for their members, and are to work with physicians, pharmacists, and payers alike to ensure that patient safety is realized, and that cost-effective therapy is achieved.

Pharmacy Payment Services

Ramsell Public Health Rx’s pharmacy payment services provides the flexibility to pay the pharmacy directly.

Quality Assurance

Ramsell Public Health Rx considers continuous quality improvement a high priority. We develop a quality assurance plan with custom-tailored parameters that allows each program sponsor to evaluate overall service quality.
Key areas under quality assurance include measures of program access and availability to clients, reviews of prescription service delivery, claims quality assessments, and management of confidentiality. We employ the use of client and pharmacy grievance procedures, as well as periodic client and pharmacy provider satisfaction surveys.

In addition, Ramsell Public Health Rx has developed a fraud prevention program to proactively monitor pharmacies for potential fraudulent activities. Specially developed desk audit reports evaluate pharmacy claims and, when necessary, we can provide on-site audit services.

Data Management, Demographic and Statistics

PMDC Systems™, the proprietary data management system from Ramsell Public Health Rx, sets the standard for quality and efficiency in data management. The ability to capture data in most formats – electronic, manual, paper, fax, web and telephone – allows us to serve and monitor every link in the program process.

Our system is designed to support treatment, claims processing and program administration, and generates up-to-date reports that provide information for specified time periods. These reports can be run for any date range or used to query all available data. As a result, public health entities can monitor expenditures in real time – even for the current week.

Beyond this reporting base, PMDC Systems™ provides the flexibility to meet sponsor’s ad hoc reporting needs.

Coordination of Benefits

Ramsell Public Health Rx fully supports online coordination of benefits (COB), which is the processing of claims with multiple payer sources, including Medicare. Members can be enrolled as having primary or secondary coverage through the member enrollment process. The Ramsell Public Health Rx claims adjudication system accepts coordination of benefit billing according to the NCPDP Telecommunication Implementation Guide Version 5.1 and COB processing examples. This billing standard is required for the Medicare TrOOP facilitation process. Some of the examples are defined below.

Rebate Management

Ramsell Public Health Rx provides full rebate management services and passes 100% of all manufacturer rebate revenue to the plan sponsor. 

Customized Reporting

Ramsell Public Health Rx will work with the client to ensure that specific reporting requirements are achieved.

Compliance Reporting (government, including CMS and HRSA)

Ramsell Public Health Rx’s compliance reporting program includes the following:

• The use of daily reports to review claims that fall outside of program standards
• Assessment of reports by patients using the “Client Grievance Procedure” or client survey form
• Investigation of incidents reported by involved parties (physicians, pharmacists, eligibility workers, etc)