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Strengthen PBM Compliance with Rebellis Benefit Testing & Review Services

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As Medicare Part D oversight continues to intensify, formulary and benefit coding errors by Pharmacy Benefit Managers (PBMs) remain a top compliance risk for Plan Sponsors. Ensuring that claims adjudicate accurately to your CMS-approved formulary and benefit design is not just a best practice — it’s a compliance expectation.


Annual benefit administration testing (BAT) continues to be one of the most effective tools to validate the accuracy of your Part D benefit before the plan year begins. A robust testing process ensures that:

  • Formulary drugs adjudicate correctly and apply the proper cost-sharing

  • Non-formulary and utilization management edits (PA, QL, ST) are firing appropriately

  • Transition and grandfathering rules are applied as intended

  • Cost-sharing is consistent with approved Plan Benefit Packages (PBPs)


At Rebellis Group, our Benefit Testing & Review Services provide comprehensive validation of PBM benefit configuration, claim adjudication, and system logic against your CMS-approved files.


Our Standard Benefit Test Suite Covers:

  • Formulary/Non-Formulary and Part D Exclusions

  • Utilization Management (PA, QL, ST)

  • Transition of Care and Grandfathering

  • Copay/Coinsurance Accuracy

  • DUR and Safety Edits

  • Reject Codes and Messaging

Optional Add-On Testing Includes:

  • Platform-specific rules (e.g., Smart PA, Part B vs. D logic)

  • Complex copay structures or supplemental benefits

  • High-risk scenarios (Hospice, ESRD, Transition Exclusions)

  • PBM or internal test bed reviews

  • Post–Go-Live claim review for early issue identification


Each engagement includes a Detailed Findings Report and Executive Summary with actionable insights to strengthen compliance, improve audit readiness, and enhance member experience.


With CMS continuing to focus on formulary administration accuracy through Cost Sharing Administration Analysis (CSAA) and audit modules, benefit testing is essential to mitigate risk and maintain oversight.


If your plan is transitioning PBMs or preparing for the 2026 benefit year, now is the ideal time to schedule testing.


Contact Rebellis Group to learn how our experts can help your organization ensure compliant, accurate, and member-focused benefit administration.



 
 
 
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