Discover how we are the partner that delivers
RxEDO works closely with our MCO clients to define “best practices”. We work together to understand the benefits for each group, within each block of business, for each client. We believe that understanding the benefits is important, but understanding the client’s approach to handling and supporting their business is even more important.
Our goal is to allow our MCO clients to focus on their specific objectives by striving to provide the highest levels of service and support in the industry. At RxEDO, our clients are truly our #1 priority.
Medicare Part D Solutions
RxEDO diligently focuses on strengthening your Medicare Part D program through expert guidance, oversight and leadership. We partner with Plan sponsors to monitor and improve your Star Ratings.
RxEDO partners with Plan Sponsors to ensure CMS guidance and regulations are adhered to in all aspects of Medicare Part D programs. RxEDO offers proven midyear implementation strategies as well as new benefit year implementation strategies based on years of Medicare Part D knowledge.
Medicare Part D Services
- Part D Formulary Support
- Medication Therapy Management (MTM)/Drug Utilization Review (DUR)
- Explanation of Benefit (EOB) Processing
- E-Prescribing Formulary Management
- Pharmacy Network Administration
- Coverage Determinations (Prior Authorizations)
- Rebate Contracting and Management
- CMS Reporting & Support
- Prescription Drug Event (PDE) Processing
- PDE Error Resolution
- CMS Audit Support
- Pharmacy Member Services
- Network Pharmacy Audits
- Quality Assurance
- Part D Reporting Submission
- Health Plan Management System (HPMS) Support
- CMS Guidance Updates
- GeoAccess Reports
- Part B Processing
- Mid-Year Implementation
- Plan Finder Submission
- Medicare/Medicaid Dual Coverage
- Transition Letters
- DMR Approval/Denial Letters
- MIPPA Compliant
CMS Compliance
The combination of clinical and operational Medicare Part D expertise enhances compliance with CMS requirements.
- Integrated Review Approach– Determining the potential impact of benefit changes specific to your Part D program aligned with federal and state legislative reviews.
- Positive Regulatory Relationships- Working closely with Plan sponsors to interpret CMS regulations and guidance.
- Proactive Process- Staying up to date with CMS changes and provide proactive consultative services to assist clients in managing their program to exceed compliance.
- Expert Prescription Drug Event (PDE) Error Analysis & Resolution- Proficiency in PDE management results in positive financial outcomes.
- Audit Support- Expert support of CMS audits and the various operational compliance focus areas.
Preauthorization
- Seamless PA management for our customers
- Web-based, real-time fully integrated PAHub rules engine and connectivity
- Eligibility
- Authorizations and Pre-Adjudication
- CMS and URAC accredited clinical criteria
- E-prescribing connectivity and network access to over 400,000 physicians EHR and 43,000 pharmacies
- Prospective prior auth using eligibility
- Increase automated PA adjudication
HIM Solutions
The Health Exchange Marketplace (HIM) is an online marketplace that provides “affordable” health care coverage for Americans. HIM’s offer income subsidies for those members that meet poverty level income, and household size restrictions. The Exchange offers different metal levels of coverage Bronze, Silver, Gold, and Platinum. These levels are based on the coverage or qualities that are offered by the insurance company. All Exchange providers no matter the level must meet the following requirements:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitation and habilitation services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
At RxEDO we offer solutions to keep our clients compliant with all Federal and State Regulations. We continually research and stay in front of any forthcoming amendments to the Federal or State regulations or requirements.