Core Services
Claims processing
The nucleus of Pharmacy BenefitDirect is our state-of-the-art claims processing platform, which features 100% electronic, real-time, on-line pharmacy claims processing 24 hours a day, seven days a week, from coast to coast.
Developed over the past 25 years, our system can accommodate all of your specialized requirements. The accuracy of our system will help you regain control of your pharmacy benefit costs. We will work with you to anticipate future market demands, as well as grow and change with your needs over time.
Real-time, on-line electronic claims transmission offers virtually unlimited options in plan design, including fixed copay variations, percentage copays, front-end deductibles, maximum benefits, and a variety of individual patient controls. In most instances, we can respond to requests for plan design changes within 48 hours, depending on complexity.
Proprietary software
Our proprietary software provides the flexibility to customize our system for each new client, from complicated benefit designs to expansive reporting requirements. For example, we can run multiple pharmacy networks for the same client; administer distinct benefit designs for multiple employers under a common Third Party Administrator; or offer real-time interfaces between pharmacy and medical claims systems to track a combined deductible.
Since we develop our own software in-house, client-requested updates (such as benefit re-design, formulary changes, or any other strategic needs a client may wish to implement to more effectively manage their pharmacy benefit) are accomplished quickly and seamlessly.
Remote access
We recognize that real-time transmission of information is essential when administering your pharmacy benefits. Remote access allows our clients to perform a variety of functions in-house, such as real-time eligibility adds, edits, deletions, or overrides. Using simple screen inquiries, you will have instant access to plan-specific data like pharmacies, cardholders, and group listings. Remote access enables the continual interactive exchange of information between the payer/client and BenefitDirect, and provides clients with the ability to create their own ad hoc reports.
ID cards and member materials
We can produce traditional credit card-style plastic cards/mailers as well as paper (punch-out) cards in-house. We will incorporate your logo into the ID card design. Alternately, you can supply us with your own card stock or issue your own ID cards.
Member materials are developed in conjunction with the client and shipped (direct to members or bulk-shipped to the client's facility for distribution) according to the client's specifications.
Dedicated customer service units
Our call center, staffed by agents who are at a minimum pharmacy technicians, is equipped to answer client, pharmacy, and member calls. In addition, we offer client-directed flexibility – our call center agents can enter overrides, prior authorizations, direct member reimbursements (DMRs), and universal claim forms (UCFs) according to the client's specifications.
BenefitDirect has developed an in-house "Help Desk Assistant" (HDA) database which is populated by the call center manager. This searchable real-time, on-line internal "program guide" is utilized by all call center agents to respond to issues while they are on the phone with a pharmacy or member. The HDA database includes client-specific information regarding benefit structure and clinical criteria.
Customized cash management options
The benefit of using BenefitDirect for your cash management needs is our positive pay arrangement with our bank. Positive pay allows us to watch for fraudulent checks or checks that are in error.
Our system has the flexibility to accept customized payment requests. Our clients commonly use the following options:
- Limited Involvement – PDMI cuts checks to pharmacies on the client's check stock. Under this arrangement, PDMI provides only a printing service and does not handle the dollars associated with funding. The client is responsible for reconciling accounts, answering questions, and balancing the account.
- Pay Cycle – Every two weeks, PDMI invoices the client for the dollar amounts owed to pharmacies. Once we receive funding, PDMI automatically cuts and sends checks to pharmacies. Either all claims from all groups for the two-week period will be released or no claims payments will be released. In addition, clients can pre-fund so payments disburse immediately.
- Off-Cycle – This option offers the latitude to selectively suspend payments for designated clients, enabling individual pharmacies to be paid for all other released claims. For example, a pharmacy may need payment from groups 1, 2, and 3. If group 1 is the only group that supplied funding, you can release group 1 payments but suspend payments for groups 2 and 3. Payments are released bi-weekly.
- Twice Cycle – After the 15th and last day of each month, PDMI invoices the client for the dollar amounts owed to pharmacies. Once we receive funding, PDMI automatically cuts and sends checks to pharmacies. Either all claims for all groups for the specific cut-off period will be released or no claims payments will be released. In addition, clients can pre-fund so payments disburse immediately.
- Weekly Cycle – At the end of each week, PDMI invoices the client for the dollar amounts owed to pharmacies. Once we receive funding, PDMI cuts and sends checks to pharmacies. Either all claims for all groups for the seven-day period will be released or no claims payments will be released. In addition, clients can pre-fund so payments disburse immediately.
Unbundled admin fees
BenefitDirect offers unbundled administrative service fees based on your unique benefit design and budget requirements. You only pay for the services you use.
Our services are packaged to evolve as your needs change, implementing modifications without disrupting other parts of your program. Therefore, you do not have to switch pharmacy benefit administrators when you want to replace a single service component to improve plan performance.