Audit Every Claim

Validate performance

Make sure that your PBM is living up to pricing and performance commitments. Trivantage believes that it is essential to perform an annual audit of all pharmacy claims for a designated time period. As one of the nation’s leading auditing firms, our criteria and processes have set the bar in terms of how PBM’s should be audited.

Why Trivantage?

• Trivantage has no interest, influence or affiliation with any PBM, maintaing the highest level of independence and objectivity
• Proprietary ‘cutting edge’ audit process that reviews at a minimum, 89 key attributes leaving no stone unturned
• A proprietary secured stand-alone system with no outside access, ensuring the security and confidentiality of all data
• Industry leading logic for the treatment of reversals resulting in credible and accurate results

Our business intelligence logic was developed with over 200 years of experience from the medical, pharmacy benefits, insurance and transaction processing industries with a solid technology underpinning.

The Trivantage claim validation process re-prices 100% of pharmacy claims for the contracted audit period (at time of fill) to ensure that the proper discounts and dispensing fees are being achieved. We analyze a minimum of 89 criteria and the following is a sampling of attributes that are reported and analyzed in the Trivantage claim audit process:

• Claims pricing validation and audit utilizing First DataBank and Trivantage’s proprietary software application
• 11 digit vs. 9 digit NDC billing and discount calculations
• Removal of Generic Drugs that enter the market under the Hatch-Waxman legislation. Sole-source generic drug claims will be excluded from the discount guarantee calculations until such time as multiple manufacturers exist, or for only the first six months from the day of the first generic drug approval, whichever comes first, as defined by First DataBank.
  • Identification of Brand and Generic reclassifications.
• Matching Reversals to Paid claims
• AWP pricing errors
• Claims filled at nonparticipating pharmacies (when pharmacy network information is available)
• Retail Brand dispensing fee analysis
• Retail Brand dispensing fee adjudicated cost basis review

• Retail Generic dispensing fee analysis
• Retail Generic dispensing fee adjudicated cost basis review
• Mail Brand dispensing fee analysis
• Mail Brand dispensing fee adjudicated cost basis review
• Mail Generic dispensing fee analysis
• Mail Generic dispensing fee adjudicated cost basis review
• Retail Brand and Generic actual discounts achieved:
  • Total Cost
  • Member Payment
  • Prospect Payment
  • Zero Balance Claims analysis
• Mail Brand and Generic actual discounts achieved
• Hatch-Waxman generics evaluation
• Review of top Non-Drug Items and overall discount achieved
• Review of top generic MAC drugs and overall generic discount achieved
• Review of top OTC items and overall discount achieved
• Administrative Fees
• Sales Tax
• Analysis and review of:
  • Brand and Generic claims reclassification
  • Obsolete Drugs
  • DAW Overrides
  • Invalid NDCs
  • Removal of Compound Drugs
• Review of suspect Duplicate Claims Payments
• Review of Prior Authorizations (when reference list is provided as benchmark)
• Review of Days Supply Limitation adherance
• Review of Top Specialty Drugs and overall discount achieved
• Review of Compound drugs and achieved discounts
• Analysis of plan excluded drugs (when reference list by GCN, HIC or NDC is provided as benchmark)