Pharmacy Claims Processing

An on-line computer network transmits prescription information from the pharmacy to the central computer. It is then checked against stored data to determine whether it can be approved for payment.

The check determines:

• if the drug is a benefit,
• if the beneficiary has health coverage and what type,
• if the quantity dispensed is within appropriate levels,
• if the number of prescriptions for the beneficiary is within limits,
• if the prescription is a duplicate or possible duplicate of another dispensed prescription,
• if the prescriber is authorized and if the unit costs are within limits.

The results of the check and cost information is then transmitted back to the pharmacy, detailing the consumer share and Drug Plan share.

Claims processing also includes Special Support assessment, reimbursement to beneficiaries for prescriptions purchased out of province, selection of certain approved claims for verification with the beneficiary, and assistance to pharmacies and consumers via toll-free telephone lines.