National 24/7 Drug Claims Management System
ClaimSecure provides Canadian corporations and their employees with an on-line, real-time drug claims adjudication service that is connected to 99% of the licensed pharmacies across Canada.
This claims management system requires that every electronically transmitted prescription pass through over 100 checks and edits prior to the drug claim being accepted, adjusted or rejected.
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Concurrent Drug Utilization Review
Patient history is reviewed in real time and checked against:
- Therapeutic duplication
-
Excessive utilization
- Too high/low daily dose
- Drug-drug interactions
-
Drug-age and/or sex
Flexible Plan Design Options
- Generic substitution
-
Preferred Provider Network - pharmacy chain level only
-
Tiered Co-payment - flat dollar, percentage or combination
-
Brand vs. generic
-
Government vs. non-government
-
Pharmacy chain
-
Therapeutic price substitution
-
Managed cost formulary (with Special authorization service)
-
Exception coverage –group/division/patient level (dollar limits and date range)
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Deductibles/maximums
-
Coordination of benefits - private and provincial
-
Step therapy
-
Trial prescription
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90 days maintenance drug supply
National Coverage – Percentage of Pharmacies Submitting Electronic Drug Claims
ClaimSecure’s card is recognized and accepted throughout Canada. ClaimSecure utilizes the most advanced communication protocol available – Canadian Pharmacy Association version 3 (CPhA ver.3) when performing real-time claims management services.
Drug claims that are submitted by providers and members
on a reimbursement basis are also subject to the same standard
of checks and edits normally applied to electronically transmitted
claims.
| |
| 179 |
179 |
100% |
| 36 |
35 |
96% |
| 238 |
238 |
100% |
| 159 |
159 |
100% |
| 1408 |
1408 |
100% |
| 2669 |
2669 |
100% |
| 289 |
286 |
99% |
| 362 |
344 |
95% |
| 770 |
770 |
100% |
| 712 |
698 |
98% |
| 18 |
18 |
100% |
| 6840 |
6804 |
99% |
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ClaimSecure’s drug management system is designed to ensure that member/dependent eligibility, therapeutic choice and cost containment measures are strictly adhered to at the pharmacy level.
To utilize the system, the covered individual simply presents the ClaimSecure pay-direct health card to the pharmacist along with the written prescription. The pharmacist electronically transmits claim information to ClaimSecure’s central computer system. Within seconds the patient’s history is reviewed, the claim status is reported, the transaction is approved (or declined) and customer out-of-pocket expenses are limited to deductible or co-payment. All transaction data is stored in the central data warehouse for reporting, invoicing and future data mining.
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