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Part D Rejected Claims Review: An Ounce of Prevention is Worth a Pound of Cure

Updated: Apr 3

Co-Authored by Debra Devereaux and Roxanne Newland

Where Medicare programs are concerned, no platitude could be more relevant. CMS releases the Readiness Checklist so plan sponsors can ensure that systems, programs and processes have been reviewed and determined to be compliant…or not. The first quarter of the year, especially January is critical to demonstrating CMS compliance in the Part D claims adjudication system. If comprehensive benefit administration testing has been completed in the last quarter of the plan year, most of the formulary and benefit coding issues should have been discovered and corrected.

Previous experience, however, has shown that most plan sponsors accept the results of their PBM’s tests without really digging into the details.

Most PBMs offer a daily rejected claims report. You can start with this report or request all the rejected claims to review in an Excel format.

The best process is to:

  • Sort the claims by reject code

  • Prioritize the reject codes for review

    • Claims that should have paid in transition

    • Protected Classes medications

    • Maximum daily doses NOT approved by CMS as utilization management edits

    • Formulary medications

    • Prior authorization

    • Unbreakable packaging

    • Short cycle dispensing

    • B vs D

  • Reject messaging

    • Does the reject messaging to the pharmacy match the rejection code?

    • Is the reject messaging clear as to next steps?

  • Claim cost-share

    • Review some samples to assure that calculations of member and plan cost share are accurate

The last and most important part of rejected claims review is timely outreach to prescribers, members and/or pharmacies. If rejected claim review is delegated to the PBM, who is responsible for the outreach efforts? If the BIN-PCN or DOB is missing, there needs to be a call to the pharmacy. Outreach to the prescriber and/or member may be needed to determine Part B vs Part D coverage.

Through daily rejected claim review, adjudication errors can be discovered and corrected early to increase member satisfaction thereby decreasing CTMs and Grievances.

For assistance with rejected claims review and disposition



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