What is the Intelligent Network
A real-time service that connects more than 50,000 of US pharmacies to over 1,000 payers, handling over 23 billion pharmacy healthcare transactions per year
What is the intelligent network also known as?
The Switch
What is the Intelligent Network Value Prop
The intelligent network connects pharmacies and payers to process prescriptions in real time. There is no need for direct connections. Pharmacies can add services to optimize reimbursement, improve workflow, and lower audit risk. Pharma gets better brand access and visibility
Network functionality can be sold through two channels
vendor can be a reseller or CMM can contract directly with an organization
Two ways to connect to the Intelligent Network
eClaims or Lease line (VPN which is a direct dedicated connection)
Customer Types
Retail Chain, Health System, Community Outpatient, Specialty, Digital and Mail order
A pharmacy vendor must use what
a practice management system (PMS) that is certified with CMM and capable of processing NCPDP formatted pharmacy claims
Three types of pricing strategies
Per Transaction, Per Store per month, annual flat fee
When do we charge a network transaction fee?
Anytime a claim reaches a payer no matter the response type the pharmacy receives from the payer (i.e. paid, rejected, capture, time out, no response etc.)
How does CMM know who to bill for the transaction?
- Each pharmacy’s billable activity is grouped under a Billing Group.
- The network invoice is sent to the owner of that Billing Group.
- A pharmacy (identified by its NPI) can belong to only one Billing Group.
What is Lease line/circuit
This is a dedicated connection, if the transaction is received via Lease line/circuit, the billable Network activity is billed to the pharmacy/vendor that owns that lease line/circuit connection
Competitors
RxConnect CHC owned by Optum and Powerline owned by RedSail
Pass-thru transactions
a transaction received from another switch for adjudication because the payer is connected to CMM. The transaction would be billed as a pass-thru fee to the other switch because we sent it for adjudication with the payer.
CMM could also send a transaction to another switch for payers that are not connected to CMM. The other switch would bill CMM a pass-thru fee and CMM would then bill the pharmacy/vendor that sent the transaction.
6 Things the Intelligent Network Does
Streamline Claims processing, Compliance Audit, Optimize Reimbursement, Optimize Workflow, Pharma Solutions and Safety
Intelligent Network Workflow
- Provider sends prescription to pharmacy
- Pharmacy initiates Rx process and submits claim
- Claim hits applicable PPE and value add solutions
- Payer receives and adjudicates the claim
- Claim is returned from the payer
- Claim hits intelligent network
- Claim hits applicable PPE and value add solutions
- Pharmacy receives claims status as either approved or rejected
- Patient picks up or gets their prescription delivered
