Third Party Liability (TPL) Pharmacy

Core Concept: Identify retail pharmacy claims that could be added to other third party liability claims utilizing the SPN database.

Health Insurance companies often pay for claims from an enrollee’s accidents where liability is a different insurance company’s responsibility. Pharmacy claims need to be a part of the collection process. In order to add pharmacy claims to the subrogation process,  SPN can identify which pharmacy claims should be added to the medical claims.

To identify the pharmacy claims, SPN is provided a payment file of all retail pharmacy claims for a given period of time. These claims are subjected to a therapeutic class table developed by SPN which assigns a relevance code to the drug product of the retail claim based on the therapeutic class of the drug.