Contract Operations

So Much More Than Just Processing Claims

Coverage Gap

Starting January 1, 2011, the Coverage Gap Discount Program was established by the Patient Protection and Affordable Care Act (PPACA).  The program enabled eligible Medicare beneficiaries to receive manufacture discounts on Part D prescription drugs, while in the coverage gap (also known as the “donut hole”).  This means that Pharmaceutical companies must accurately process these rebates on a quarterly basis to avoid penalties and other repercussions.

Here is a list of the most common services PharmaMetrics has been providing to drug Manufacturers to manage and process their Coverage Gap invoices:

  • Act as a liaison between Clients and CSSC ( TPA for CMS)
  • Receive Coverage Gap quarterly invoices and detail files on behalf of Clients from CSSC
  • Processing of invoice and detail files and transfer of processed invoices to Clients for payment
  • Receipt of Client payment details, generation and submission of payment confirmation to CSSC.
  • Generation of dispute resolution reports and working with CSSC on dispute resolution
  • Maintaining of MCO banking information
  • Analytical reporting of Coverage Gap invoice and detail data which includes:
    • Coverage gap invoice trend over time
    • Back bills trend over time
    • Coverage gap invoice amounts by MCO,  NDC and/or Product Brand
    • Quantity dispensed and Price per unit by NDC/ Product Brand
    • Top coverage gap amounts by MCO, NDC, Product Brand etc.,
    • Historical data summary and details

PharmaMetrics is pleased to announce that we now offer Payment Processing Services to our clients. A client-specific escrow account will be setup to be funded by the client utilizing this service. All invoices processed and ready for payment will go through a client approval process before payments are made.

For more information regarding this service please contact us 215.274.1316

  •  “What sets PharmaMetrics apart is the depth and breadth of their true business knowledge.”
            -- Director, Contracts, Top 20 Pharma

  • “PharmaMetrics solutions can either be a complete business solution or independent modules that supplement your current business infrastructure.”
            -- Director, Contracts, Top 20 Pharma

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                -- Director, Corporate Compliance, Dermatological Company

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                -- Director of Contracting, Amarin Pharma Inc.

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            -- Sr. Director, Contract Management, Top 10 Pharma

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            -- Sr. Director, Top 10 Pharma