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Some situations require a pharmacist to submit a claim that, under normal circumstances, would be rejected by the third-party payer.  For example, a patient is going on a vacation and requests a three-month supply of their medication.  To prevent rejection, this claim must be submitted with a Submission Clarification Code. In this article, we look at how submission clarification codes are used and offer some best practices that may help you ensure proper reimbursement. 
How can you quickly identify potential rejections for prior authorizations, non-formulary fills, quantity supply, and step therapy requirements? The Medicare Part D Transition Policy allows some patients access to prescription drugs within 30 days of their enrollment in a Medicare Part D plan. Pharmacies need to be efficient and proactive when managing these claims.

Have you ever wondered why payers will reject some claims, adjudicate others with profits, or respond on some with losses? The answer may lay with whether the medications’ NDC (National Drug Code) is on the payer’s formulary list.  If it is on the list, what tier is it on and is it a preferred medication? The answer may affect the reimbursement amount and patient copay assignments.

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