Skipping the Claim Summary Window

This topic is intended for Independent pharmacies only and is not applicable to Rexall pharmacies.

When a prescription completes adjudication, the Claim Summary window opens automatically giving you the opportunity to manually waive differences. However, in some situations, you may want to skip the Claim Summary window if there's no manual intervention needed.

The Claim Summary window does not appear when:

  • The Patient Pays = $0.

  • The prescription is billed to Cash (CA) only. Waives cannot be applied to Cash only prescriptions.

  • The prescription is billed to offline plans only (i.e., Accounts Receivable, House Charge, Nursing Charge).

  • Skip Claim Summary is enabled and the only difference between the amount billed and the amount paid is the deductible.

  • The Patient Pays amount is equal to or below the Acceptance Threshold set in the Pricing module, Group Folder, Batch Preferences, or Patient Folder.

Skip Claim Summary

The Skip Claim Summary option allows the Claim Summary window to be skipped when the only difference between the amount billed and the amount paid is the patient's deductible. The deductible is indicated in the Patient Pays amount on the receipt. Before the Skip Claim Summary functionality is invoked, Propel Rx applies any waive amounts, followed by the Acceptance Threshold. If the remaining difference between the amount billed and the amount paid is a deductible, the Claim Summary will be skipped. If the remaining difference includes a cost, markup, or fee difference, the Claim Summary window appears.

To set the Skip Claim Summary preference:

  1. Select More (...) > Pricing > Waive Rules tab.

  2. Do one of the following:

    • If you want the preference to apply to all Third Parties, select the Pharmacy row on the pricing tree.

    • If you want the preference to apply to a specific Third Party or sub plan, select it on the pricing tree. The preference will apply when the Third Party or sub plan is the primary plan in the prescription's billing codes. If the Third Party or sub plan does not exist on the pricing tree, complete the following steps:

      1. Select the Pharmacy row in the pricing tree.

      2. Select Add to open the Create New Waive window.

      3. Dropdown the Third Party - Plan* field and select the Third Party or sub plan you want to add a rule for.

      4. Select OK once done.

  3. Select the Skip Claim Summary checkbox.

  4. Select Save.

Acceptance Threshold

The Acceptance Threshold allows prescriptions to be accepted automatically without forcing the Claim Summary window to be displayed if the amount paid by the patient is less than or equal to the value specified.

Acceptance Threshold Hierarchy

Like waives, Acceptance Thresholds follow a hierarchy with thresholds set at lower levels superseding levels that come before it. For example, an Acceptance Threshold entered for a batch will override the Acceptance Threshold entered for the group.

For more information on setting Acceptance Thresholds, select the dropdowns below.

Acceptance Thresholds can be specified for the entire pharmacy, specific Third Parties, and/or sub plans. Thresholds can also be differentiated by the type of prescription (retail versus non-retail). If there are any automatic waives set up, they will be applied before prescription is validated against the Acceptance Threshold.

Non-retail prescriptions are prescriptions filled for patients in non-retail groups. You can view whether a group type is retail or non-retail in More (...) > List Maintenance > Group Types.

To set a pharmacy wide or Third Party specific Acceptance Threshold:

  1. Select More (...) > Pricing > Waive Rules tab.

  2. Do one of the following:

    • If you want the preference to apply to all Third Parties, select the Pharmacy row on the pricing tree.

    • If you want the preference to apply to a specific Third Party or sub plan, select it on the pricing tree. The preference will apply when the Third Party or sub plan is the last plan in the prescription's billing codes. If the Third Party or sub plan does not exist on the pricing tree, complete the following steps:

      1. Select the Pharmacy row on the pricing tree.

      2. Select Add to open the Create New Waive window.

      3. Dropdown the Third Party - Plan* field and select the Third Party or sub plan you want to add a rule for.

      4. Select OK once done.

  3. Enter the desired value in the Retail Acceptance Threshold and/or Non-Retail Acceptance Threshold fields.

  4. Select Save.

Acceptance Thresholds can be specified for all patients within a particular group.

To set a group specific Acceptance Threshold:

  1. Open the Batch Manager .

  2. Select the Groups tab.

  3. Select the appropriate group.

  4. Select Detail.

  5. Select the Preferences tab.

  6. Select TP Threshold. The Group Third Party Preferences window opens.

  7. Enter the desired value in the Acceptance Threshold field.

  8. Select OK.

  9. Select Save.

Acceptance Thresholds can be specified for all patients in a batch.

To set a batch specific Acceptance Threshold:

  1. Open the Batch Preferences window.

    • If you are in the process of scheduling a batch, this window opens automatically following the Batch Refill window.

    • If the batch has already been scheduled but not yet run, open the Batch Manager. Select the Batch History tab. Detail the appropriate batch. Select Preferences.

  2. In the Third Party Threshold section, select the Batch radio button.

  3. Enter the desired value in the Acceptance Threshold field.

  4. Select OK.

Acceptance Thresholds can be specified for all prescriptions for a particular patient.

To set a patient specific Acceptance Threshold:

  1. Open the Patient Folder.

  2. Select the Third Party tab.

  3. Select Waives at the bottom. The Patient Waive Preferences window opens.

  4. Enter the desired value in the Acceptance Threshold field.

  5. Select OK.

  6. Select Save.