Immunizations, diabetic supplies, and Part B drugs that need CMS-1500 instead of NCPDP D.0.
We are a pharmacy medical billing company for independent pharmacies.
High-cost biologics, J-codes, prior auth management, and coordination with specialty distributors.
Monthly billing cycles, bed holds, multi-payer claims, and reconciliation by facility.
340B pricing, contract pharmacy rules, and documentation for audits.
In-office dispensing, ASP pricing, and medical benefit claims tied to clinic visits.
Bill both PBM and medical? We keep them separate so nothing falls through.
This is where money disappears. Most pharmacies run PBM fine. Medical is different. Different codes, rules, and payers.
We check if the drug is Part B or Part D before the patient arrives. Medical vs pharmacy benefit too.
We collect clinicals, submit PA, and appeal denials. For specialty drugs, we track renewal dates.
Payers want J-codes + NDC + correct units. 1 vial ≠ 1 unit. We convert it right so claims don’t reject.
We file to commercial payers and Medicare Part B through the medical portal, not the PBM switch.
ERA and EFT posted. Every payment matched to the claim.
For high-cost drugs, we coordinate copay cards and foundation support so patients can afford the fill.
No black box. You see where every claim is in your dashboard.
New claims are easy. Aged claims pay the bills.
Some payers allow 12 months. Others 90 days. We calendar every deadline.
Small-Balance and Write-Off Policy
| Check Type | What We Do | Why It Matters |
|---|---|---|
| Fee Schedule Validation | Compare paid amount to contract rate | Catch short-pays immediately |
| ASP, WAC, NADAC Reference Checks | Verify Part B drug pricing against published rates | Prevent underpayment on J-codes |
| Recoupment and Clawback Review | Audit take-backs and appeal if wrong | Recover money already paid |
If a payer takes money back 6 months later, we find it and fight it.
Pharmacy revenue cycle management isn’t one person doing data entry. It’s a system.
You can’t bill medical until you’re enrolled.
Express Scripts, CVS Caremark, Optum Rx, Humana. We handle the applications.
For diabetic supplies, nebulizers, and other Part B items.
Rules vary by state. We manage each application.
We track revalidation dates so you don’t get dropped.
We review contracts and handle re-credentialing every 3 years.
If you use a PSAO, we coordinate enrollment through them.
Medicare Part B: 60-90 days. Commercial: 45-120 days. PBM: 30-60 days. We give you real timelines upfront.
We don’t make you switch systems.
PioneerRx, Liberty, BestRx, PrimeRx, QS/1, Rx30, Computer-Rx, FrameworkLTC
We get access and start working inside your current setup.
Billing rules aren’t national. Medicaid in Florida is different from Medicaid in California.
If you ship across state lines, we follow each state’s rules.
Coverage for Part B drugs and supplies varies. We know the differences.
We handle billing for central fill and mail order pharmacies.
We provide outsource pharmacy billing services in USA for pharmacies in every state.
One salary = salary + benefits + training + PTO. Our fee is % of collections or flat monthly.
Claims get worked 5 days a week. No gaps when staff is out.
Our team codes J-codes, NDCs, and Part B claims every day. Not hospital claims.
This is why pharmacies choose us as their pharmacy billing company.
Switching shouldn’t disrupt fills.
We get access, review payers, and pull a snapshot of aged A/R.
We start working aged claims and submit new ones.
You get a call every week and a report every month.
Top 3 denial reasons so we can fix the root cause.
Cost is simple.
You pay a 3-8% of what we collect. No collection, no fee.
Month to month. Stay because it works.
Everything above. No hidden fees for calls or appeals.
Pharmacies get audited.
Encrypted systems, access controls, and staff training.
If a PBM or payer audits, we pull the packet: prescription, PA, delivery proof, claim.
We sign a BAA and limit access to only what’s needed.
Pharmacies stay with us because we get claims paid and make billing simple.
Pharmacy billing uses NCPDP D.0 through a PBM. It’s for retail scripts. Medical billing uses CMS-1500 or 837P. It’s for Part B drugs, supplies, immunizations, and DME. Insulin is pharmacy. An insulin pump is medical. If you only run PBM, you miss 20-30% of revenue. Our Pharmacy Billing Services handle both.
Yes, if you’re enrolled in Medicare Part B and DMEPOS. Drugs: post-transplant immunosuppressants, oral anti-cancer drugs, drugs through DME. Supplies: diabetic supplies, nebulizer drugs/equipment, infusion pumps. Each has rules. We verify eligibility first.
Often yes. POS denials happen because it’s covered under medical. Example: a nebulizer drug rejected at POS may be Part B. We check within 24 hours and refile to medical if needed.
Independents, specialty, LTC, and hospital outpatient. 80% of our clients have 1-5 locations.
PBM: 30-60 days. Medicare Part B: 60-90 days. Commercial: 45-120 days. State Medicaid: 60-120 days. We follow up weekly.
80+ systems. Pharmacy: PioneerRx, Liberty, BestRx, PrimeRx, QS/1, Rx30. EHR: Epic, athenahealth, eClinicalWorks. No system change needed.
Two options: % of collections or flat monthly. % works for specialty. Flat works for high-volume retail. No setup fees.
Yes. We pull the packet: prescription, notes, PA approval, proof of delivery, and claim.
3 steps. Fix the cause. Appeal with the right docs. Track by payer. For underpayments, we compare to contract and file.
Yes. We provide Pharmacy Billing Services in all 50 states.
Ask 3 things:
If not, they’re generalists.
