Drug Report to Member Audits

HMSA has retained Health Management Systems, Inc., DBA Prudent Rx to assist in research and follow-up on member inquiries about the accuracy of information included in the quarterly HMSA Drug Report to Member (RTM). We have updated this process to ensure that HMSA members receive timely responses to their inquiries.

RTM Inquiries

The RTM provides members with detailed information about their drug claims, including:

• Patient’s name
• Name of dispensing pharmacy
• Prescribing physician
• Prescription number
• Name of drug
• Days supply
• Quantity
• Retail cost
• Member’s out-of-pocket cost
• Member’s benefit

In some instances, members question the accuracy of information contained within their drug benefit report and subsequently contact HMSA's Customer Service Department. Examples of member comments include, “I don't take this medication”, “I did not fill this prescription on the date specified”, and “The physician listed on my drug report is not my physician”.

In some instances members may have a poor recollection or partial history of events. The patient may have simply forgotten he/she had received a prescription, or a member may be unaware that his/her spouse picked up a medication for a child. These situations are resolved by checking recipient signatures contained in the pharmacy’s dispensing log. However, the majority of drug RTM inquiries are generated by inaccurate claims information submitted by pharmacies.

RTM audit process

Prudent Rx has created an audit module to assist HMSA in evaluating the accuracy of pharmacy claims associated with RTM inquiries. This RTM audit is distinct from Prudent Rx's standard, monthly desktop audits.

HMSA’s Customer Service Department will forward reports of inaccurate claims information to Prudent Rx. Prudent Rx will contact the dispensing pharmacy and request prescription information and any supporting documentation related to the claims. The pharmacy has five business days to respond to the request.

Upon receipt of the requested information, Prudent Rx will review and make a determination on the accuracy of the prescription and fax the results to the pharmacy within three (3) business days. At that time, the pharmacy will have five (5) business days to file an appeal, if warranted.

Appeals process

To file an appeal, the pharmacy should provide the specifics as to why the results are in dispute and include any additional supporting documents not previously submitted. The appeal request, along with the supporting documentation and a copy of the results letter, should be faxed to the Prudent Rx audit department at 1-310-642-1701. Or the material may be sent to:

Audit Department – HMSA RTM Audit

Prudent Rx, Inc.

100 Corporate Pointe, Suite 395

Culver City, CA  90230

Upon receipt of any supporting documentation, Prudent Rx will make a final determination and report its findings to HMSA. The RTM audit will result in a finding of either:

No Adjustment – The claim was found to be acceptable and no further action is required by the pharmacy; or

Adjustment – The claim has an error, and is therefore subject to recoupment. Prudent Rx will contact the pharmacy explaining the recoupment process.

Pharmacies should ensure that the information submitted on claims is complete and accurate. Submission of inaccurate prescription claims:

• Compromises benefit integrity, which may have negative financial consequences for HMSA employer groups and members
• May reduce patients’ confidence in their pharmacy provider
• Corrupts pharmacy data used to support various HMSA quality programs which are designed to optimize care for our members

For questions regarding specific RTM audit situations or requested documentation, please contact the Prudent Rx Pharmacy Audit Department directly at 1-310-642-1700.

Revision History