Retro Term OPIS™

Core Concept: Identifying retail pharmacy claims that have been paid for ineligible members of a health plan.

Identify and recover retail pharmacy claims where the health plan had inadvertently paid claims for patients which no longer have coverage under the health plan.

Health plans routinely receive eligibility information from employers that is inaccurate. This leads to health plans paying for retail pharmacy claims for employees that either no longer have coverage or where the employer group has switched health plans and has failed to notify the health plan in a timely manner.

The OPIS system has the ability to load retail and eligibility information, identify patients whose coverage has terminated and facilitate recovery from the patient or assist the employer in re-submitting patient claims to the correct health plan.