Medical Pharmacy OPIS™

Core Concept: Identifying, validating and recovering paid medical claims that represent pharmaceutical care.

This product is the core or flagship product of SPN. Paid medical claims are entered into SPN’s OPIS™ database. These claims then are subjected to a library of edits called PEDS (pharmacy edit documentation), which identify medical, retail or specialty pharmacy claims that have been inaccurately paid due to financial, clinical or procedural errors. These identified claims are then organized as inventory and presented to a user on the OPIS system referred to as a validator. The validator reviews the claims and validates the PED’s accuracy. Once the accuracy of the overpayment is confirmed the claim is then presented to a recovery specialist, who in turn utilizes the OPIS application to contact the provider and request overpayment. The entire cycle of identification, validation and recovery is done through the OPIS application.