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Pharmacy Claims
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Drug Claim Adjudication
Online claims processing ensures accuracy almost instantly and can
improve member safety. Within seconds, claims are processed to provide
eligibility and drug coverage verification, copay information, and
drug utilization reviews. Online coordination of benefits (COB)*
is possible with public and private sector plans. Claims can be
processed online in real-time or using the deferred payment* process.
ESI Canada also offers manual claims processing services.
Adjudication Controls
Many built-in system controls ensure that the appropriate amount for a claim is paid. These controls include positive
enrollment, days supply, and dispensing fee controls.
Drug Plan Management
ESI Canada's pharmacists continuously look for new ways to manage
drug plans and provide alternatives to traditional plan designs.
Each month, our in-house clinical staff members conduct extensive
reviews of scientific and clinical data to evaluate new drugs for
their place in therapy, impact on drug plans, and fit with clinical
programs. ESI Canada manages hundreds of customized drug plans as
defined by our customers.
Here is a sample of the tools used to manage drug plans:
Drug Utilization Review
The sophisticated drug utilization review (DUR) system monitors
claim adjudication, enhancing member safety while helping contain
costs. Every prescription, no matter at which pharmacy it is filled, is screened for potential problems such
as drug interactions, duplicate therapies, early refills, and, if
selected, drug allergies. A message to the pharmacy flags potential
complications or abuse, allowing the pharmacist to consult with
the patient and, if necessary, the prescribing physician.
More information is available about how drug utilization review* can provide plan members with more safety when they fill their prescriptions.
Pharmacy Network Management
ESI Canada maintains contracts with virtually all Canadian pharmacies, both chains and independents. The company arranges for the bulk payment of pharmacy providers to reduce costs for insurance carriers, third-party administrators, and the public sector.
Reporting
RxReports* is a series of 21 predefined, online detail and summary
reports that customers use to assist in managing prescription drug
benefits. Prescribing patterns and ranking measurements help identify
drug usage trends by therapeutic class and individual drug. Reports
are available by group, pharmacy provider, or drug. Additional ad
hoc reports are available on request from an extensive database
to gather information on the performance of a group's drug plan.
Clinical Services
ESI Canada recognizes that there is more to drug claims cost management than claim adjudication. By harnessing the potential of technology, drawing on the expertise of the in-house health management services team, and using established medical guidelines and protocols, ESI Canada develops medication management products that emphasize the use of quality, cost-conscious drug therapy.
Learn more about the clinical work done by our industry-leading
drug evaluation committee.*
Pharmacy Benefit Audits
ESI Canada's audit programs* verify that claims are paid for authorized
prescriptions only and that pharmacies price within their contractual
limits. These audits help eliminate waste and manage costs, with
proven savings to our clients. ESI Canada participates in a
number of industry audit initiatives, including the
Canadian
Health Care Anti-Fraud Association (CHCAA).
Drug Database
ESI Canada offers its customers access to a comprehensive database
of drug identification numbers (DINs), drug prices, generic interchangeability,
and regulatory schedules.
Learn more about how our drug price files* are updated.
* Adobe® Acrobat® Reader® Required
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