Purpose This reconciliation is designed to match the claims (the portion of the prescription cost that the pharmacy has to collect from an insurance provider) to the payments received from the insurance providers. This is typically done at the detail level, meaning each prescription filled with a portion to be collected from the insurance company will have a transaction in the file from the pharmacy and each payment file will also have a detailed record for that claim. The transactions are typically matched by prescription number and refill number.
So, pharmacy claims is basically a straightforward reconciliation in it's elementary description. There are complications that have to be handled, such as:
Each insurance provider uses a different file format for payment detail transactions
There are often 50 or more providers to be dealt with
Some cases require two claims, first a government claim which is followed by a claim sent to a private insurance carrier for the portion that the government does not pay
The actual funds for the payment are received separately from the file containing the details of the precription claims that are included in the total payment amount. This requires a reconciliation of the total of claims in the payment detail file to the funds total to be sure that funds have been recieved before attempting to match the claims detail to the payment detail.
