What Is a Claim?

A medical claim is an invoice a doctor, or medical facility, sends to a health insurance company after a patient receives care. It provides details on the services the patient has received and the associated charges set by the doctor, or facility.

What Is Claims Processing?

Claims processing is an intricate workflow involving checkpoints that every claim must go through before it’s approved. If a claim makes it through all these checkpoints without issues, the insurance company approves it and processes any insurance payments. If it doesn’t, it gets denied, or sent back for more information.

pharmacy claims processing
Our Claims Processing Model Offers:
  • Shorter reimbursement period as compared to traditional mailing of HFCA forms
  • No additional billing staff requirements
  • Real time claim payment and status information – at the time of dispense

First Coast works with clients to develop customized electronic solutions that are designed to accelerate the revenue cycle. Our executive team has experience to work specifically with several variations of non-pharmacy dispensing sites.

Non-pharmacy Dispensing Sites
  • Realtime adjudication
  • Complete dispensing and inventory management
  • SureScripts™ certified E-prescribing
  • Complete software and database tools
  • Flexible revenue cycle management
pharmacy claims processing

NCPDP Claims Adjudication:


NCPDP creates national standards for electronic healthcare transactions used in prescribing, dispensing, monitoring, managing and paying for medications and pharmacy services. They  also develop standardized business solutions and best practices that safeguard patients.

Your organization can now utilize NCPDP 5.1 to adjudicate claims immediately after dispensing. 

Within seconds, the claims are ‘factored’ and the reimbursement amount is known. “Factoring” means the claim is purchased and cannot be returned, even if reimbursement is not received from the payer.

Claim adjudication experts resolve any missing data or problems with claims from a central location. This usually involves obtaining missing information from the practice through the software’s help desk system.

In most states, reimbursement amounts are based on AWP and vary from state to state depending on several factors, including the prevailing reimbursement rate for any specific state workers’ compensation program.

Benefits of Pharmacy Claims Adjudication:

  • Quickly and efficiently verify coverage eligibility. You and your team can focus your time on your patients instead of spending time on the phone
  • Our experienced team is available online and over the phone to support you at every step
  • Effectively manage this small but profitable segment of your business
  • Achieve the results you need to effectively measure your members’ pharmacy benefit management experience
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3.7/5 (3 Reviews)