We provide NCPDP Telecommunication Standard electronic claim adjudication services designed to meet individual program dispensing guidelines and plan rules or limitations. Ramsell Public Health Rx’s claims adjudication system is robust and flexible, enabling complete control of your plan benefit. Flexible rules can be established to contain costs and efficiently manage the claims process.

These plan rules include, but are not limited to:

• Formulary drug coverage
• Prior authorization requirements
• Dispensing controls and limitations
• Step therapy and prerequisites

Our 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 work collaboratively with physicians, pharmacists, and payers alike to ensure that patient safety is realized, and that cost-effective therapy is achieved.

Our fully supports online COB, which is the processing of claims with multiple payer sources. The Ramsell Public Health Rx claims adjudication system accepts coordination of benefit billing according to the NCPDP Telecommunication Implementation Guide as named in the HIPAA Final Rule for the Transactions and Code Sets published in the Federal Register by the Department of Health and Human Services.

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.

Our Electronic Eligibility Verification System (EEVS) is a user friendly telephony system providing access to client eligibility information 24 hours a day, 7 days a week. It reduces the time required to verify eligibility and benefits, and provides more comprehensive information than most system, pulling data securely and directly instantly at the point of care.

Our secure system provides HIPAA compliant enrollment and eligibility information handling. Whether the 834 Electronic Data Interchange (EDI) file or proprietary enrollment process, Ramsell Public Health Rx can facilitate program enrollment and eligibility data to ensure accurate identification of eligible members and storage of enrollment data.

Additionally, we can provide enrollment and eligibility administration, enrolling members into the plan benefit on behalf of the program. With over 15 years of enrollment and eligibility administration, Ramsell Public Health Rx is poised to manage your program’s enrollment and eligibility data.

Program sponsors have the flexibility to design a number of different formulary coverage levels. We can employ the use of your program’s defined formulary or a standard formulary benefit on behalf of your program. 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.

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 geographically mapping service areas and selecting pharmacies that fulfill 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.

We consider 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.

We provide rebate administration services and full disclosure of manufacturer rebate revenue and fees. Transparency is a major tenet of the Ramsell Public Health Rx rebate service. Program sponsors can be assured of visibility of rebate transactions on a timely basis.

We provides a configurable reporting system that enables access to program data 24 hours a day, seven days a week, 365 days a year. These reports can be run for any date range or used to query all available data. As a result, entities can monitor expenditures in real time – and have real time access to reliable program data.

In addition to the reporting system, Ramsell Public Health Rx provides the flexibility via custom reports and ad hoc reporting.