TransactRx Part D Physician Network Grows to Over 30,000 Physicians

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Transaction Platform Processes over 2 Million Patient Encounters

We are working on many projects related to specialty drugs, medical drugs rebates and retail walk-in clinics where products and services are covered under the medial benefit can be more effectively managed on a pharmacy platform

TransactRx announces that its Part D Physician Network has processed more than 5 million Real Time Benefit Inquiries and Pharmacy Claim transactions for Medicare Part D covered immunizations administered in physician offices related to over 2 million patient encounters. The TransactRx Part D Physician Network was created in 2008 when TransactRx was presented with a challenge from a large pharmaceutical manufacturer to solve reimbursement barriers for physicians to bill for vaccines that were previously covered under the medical benefit but were moved by CMS to the Part D pharmacy benefit.

TransactRx created a two-part solution consisting of a national provider network and a specialized “Transaction Platform”. The provider network contracts with physicians and with the Medicare Part D plans and their PBMs, on behalf of the Network, for reimbursement of vaccines administered in the physician office. The Part D Network is currently contracted with over 30,000 physicians in all 50 states and Part D plans that cover over 90% of Medicare Part D lives. The Transaction Platform enables contracted providers to submit pharmacy benefit Eligibility, Real Time Benefit Inquiries and claims, as in network providers, all while staying within their normal medical billing workflow. The Transaction Platform also supports a number of different interfaces to receive and process Part D transactions including a TransactRx web based physician portal, acceptance of standard X12 837 professional medical claims through a number of the largest medical claims clearinghouses, REST API’s for software developers that have physician office applications to easily interface and support for proprietary interfaces.

The Program provides a solution to 1000’s of Health Plans that without, would have no way to easily process these claims for their members. The solution was so critical that TransactRx was delegated credentialing and all payment processing responsibility. The Platform is fully automated to enroll, validate credentialing, activate accounts, process claims, and pay all Network Providers. Providers receive one consolidated and easy to understand EOB across all plans with payments made via ACH or Check. This includes providing properly formatted 835 ERA’s to allow all A/R to be managed in their existing medical billing systems.

The initial Transaction Platform, has evolved into the TransactRx Cross Benefit Clearinghouse “Platform”. The Platform provides a seamless interface between the X12 professional medical claim processing infrastructure and the NCPDP Pharmacy transaction infrastructure. Currently the Platform connects 30,000 physicians, 5,000 retail pharmacies, 1,000 retail clinics, 500 public health departments, all major PBMs and thousands of pharmacy and medical insurance plans. This unique and proprietary functionality supports a broad set of transaction services:

  • Online fully automated enrollment platform with extensive tools for provider contracting, credentialing and account activation
  • Ability to receive professional medical claims for any product or service including infused and specialty pharmacy drugs and associated services, convert the claims to pharmacy claims and transmit to PBMs.
  • Ability to receive pharmacy claims from any pharmacy system for any product or service, convert the claims to professional medical claims and submit to medical payers
  • Provider Network management tools for establishing contract coverage rules and network transaction reporting
  • Complete payment processing functionality to act as a delegated payment processor to the payer or PBM capable of handling any volume of payments into the platform and then sending checks or ACH payments to providers.
  • Functionality to receive 835 ERA files from medical or pharmacy payers, process the ERA against submitted claims and create a new ERA that has all the original ID’s of the submitted claims allowing for automated posting by the provider system

“The Part D Network Program was the starting point of the development of the Cross Benefit Clearinghouse Platform”, says Jack Guinan, CEO, “It was the first step in developing a transaction platform that enables any benefit manager to process a claim regardless if it is covered under a Pharmacy or Medical benefit and whether it was created in a pharmacy billing or medical billing system. This model of independence from transaction standards and systems enables our clients to have greater control and flexibility in designing and managing a benefit. Today we are working on many projects related to specialty drugs, medical drugs rebates and retail walk-in clinics where products and services are covered under the medial benefit can be more effectively managed on a pharmacy platform. We are truly blurring the line between pharmacy and medical benefit management”, Guinan concluded.

POC Network Technologies, Inc. d.b.a. TransactRx provides cloud based transaction services that enable a seamless real-time interface between the medical and pharmacy claims processing infrastructures for Benefit Managers (PBMs, Health Plans, Billing and Technology Providers). Using existing systems, the TransactRx proprietary Cross Benefit Clearing House and Population Health Management Platforms provide unique and flexible solutions to help manage any type of benefit no matter if it is on the Medical or Pharmacy spend.

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Jack Guinan
+1 (800) 971-5500 Ext: 1001
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