Millions of drug claim transactions are processed annually and the accuracy of each one is critical. That's why our adjudication process contains various audit features that can alert us to potential areas of concern and, if needed, identify pharmacies that require on-site audits. In addition, we perform in-house pharmacy reviews to ensure the appropriateness and accuracy of payments.

Audit Service Features:

• Automatic audits on daily transactions
• High dollar-value claim review
• Duplicate claim review
• Compound drug claim review
• General database review
• On-site pharmacy audits
• Plan member verification
• Reject reports

How the Audit Process Works:

1. Transmission: A drug claim is sent electronically from the pharmacy to TELUS Health Solutions.
2. Verification: The EDI transaction is verified against the source of the record for corrections and provider entitlement. In addition, plan member (relationship code, date of birth, etc.) and drug eligibility are validated. Checks are conducted to identify and reject duplicate prescriptions.
3. Adjudication: The claim is adjudicated based on specific plan parameters and a message is sent back to the pharmacy in real-time with the eligible amounts and/or adjustment codes, as appropriate.
4. Data Storage: All claims are stored in our database. This allows for the generation of reports that identify claims with a high-dollar value, possible duplicate claims or compound claims. In addition, this database provides the audit department with pharmacy and plan member claim summaries. These reports are utilized to evaluate pharmacies and identify which ones are submitting claims that require further investigation.
5. Data Review and Audit Selection: A combination of electronic and manual procedures are performed:
   • Large dollar value claims are pulled systematically and reviewed daily for appropriateness
   • Compound drug and plan member mailers are sent out regularly to review whether or not the claims submitted were appropriate; all responses from plan members are reviewed manually
   • Claims that are rejected are monitored through the reject report to see if subsequent claims bearing the same claim information are resubmitted inappropriately. Based on the results of these reviews, certain pharmacies may be identified for on-site audits.
6. Selection of Audit Claims: A TELUS Health Solutions auditor researches and selects an appropriate number of claims for physical review.
7. On-site Audit: The auditor schedules an appointment and goes on-site. Prescriptions against the claims are obtained and physically audited. The auditor completes a report that identifies any issues, concerns or prescription adjustments.
8. Adjustments: All claims identified for adjustment are summarized in a notice which is sent to the pharmacy for review. If the adjustments aren't disputed, all monies due are electronically withdrawn from the pharmacy's bank account 21 days after the date of notice.
9. Credit and Final Report: The adjusted amounts are credit to the appropriate insurance carrier and an ALOG (adjustment log) file is sent at the end of each month to identify which claims were adjusted and for what amounts.