Our client manages one of the best 340B contracted pharmacy network and is a technology leader in 340B processing and automation. They wanted to enter the Medicaid market for the reclassification of 340B claims.

Application Goals:

  • Create a process for MCOs, pharmacies and 340B administrators to submit data files for claims identification.
  • Create a scalable, comprehensive and robust solution for MCOs to demonstrate to the State an effective 340B compliance and performance program across both retail and specialty pharmacy patients.
  • Identify and report to the State all Medicaid claims in which the ingredient cost was purchased with 340B discounted prices.
  • Create a solution to share 340B data, savings, performance and refunds using agreed upon standards.
  • Prepare shared savings invoices and reports and settle funds collection and payments.

Y&L created a solution containing multiple integrations/interfaces, a flexible and scalable audit rules engine and multiple web-based portals as well as delivered the following:

  • Scalable – Expected monthly claim volume of 100+ million
  • Hippa Compliance – Safeguards for handling and data transmission
  • Claims Management – Handle single and multi-payer claims and identify claims between the MCO and Entity to calculate savings.
  • Governance – Track claims from source data to invoicing rejection.
  • First -To-Market – Successfully created a new market space delivering significant revenue to client, MCOs and other entities.