Claim Capture by Provider Type: A Compliance and Maximization Guide

Claim capture by provider type is a crucial aspect of a covered entity’s 340B program.

Dec. 10, 2024 | | Written by Stephanie Blaskoski, Regional Manager, Sales, SunRx

Provider panels are lists used by 340B Third-Party Administrators (TPAs) to determine which providers’ claims are 340B eligible. At a minimum, a provider panel should include:

Provider’s eligible start date and National Provider Identifier (NPI)
Service areas they are associated with
Provider type

CEs must consistently maintain their provider panel to reflect changes in provider status.

Provider Types and Capture Logic

Accurately categorizing providers by type is essential for applying the appropriate claim capture logic. Here’s a breakdown of common provider types and their implications for claim capture:

Exclusive/Standard Providers: These providers are contracted by the CE and only practice within the CE’s eligible service areas. They are expected to adhere to the CE’s policies and procedures (P&Ps). Claims from exclusive providers can typically follow a capture logic that captures all scripts written with associated visits, as long as other eligibility criteria are met.
Non-Exclusive/Non-Standard Providers: These providers are contracted by the CE but practice both within and outside the CE’s eligible service areas. This could include ineligible service areas within the CE or facilities not affiliated with the CE. Due to their varying practice locations, claims from non-exclusive providers require capture logic that differentiates between eligible and ineligible facilities. Manual claim capture options, such as review queues or fallout reviews, can help maximize capture for this provider type.
Referral Providers: These providers see patients referred from the CE but do not practice within the CE’s eligible service areas. Claims from referral providers may be eligible for capture if they meet the CE’s referral capture criteria outlined in their P&Ps. Capture logic for referral providers must track patient care through encounter data and referral notes. Like non-exclusive providers, manual capture options can be beneficial for referral providers.

Benefits of Distinguishing Provider Types for Claim Capture

Implementing capture logic by provider type is crucial for several reasons:

Compliance: Ensuring that claims are captured according to the correct provider type is essential for maintaining 340B program compliance.
Capture Maximization: By accurately categorizing providers and implementing appropriate capture logic, CEs can maximize their 340B benefit.
Resource Optimization: Utilizing provider type-specific capture logic can reduce the strain on resources by minimizing unnecessary manual review of claims.

Next Steps for Your Organization

To ensure a compliant and maximized 340B program, consider the following steps:

Review: Assess the accuracy of provider types associated with your 340B program.
Verify: Confirm that an internal procedure exists for maintaining the accuracy of your provider panel.
Collaborate: Contact your TPA to understand your provider type and capture logic options and ensure appropriate configuration within their system.

By understanding the nuances of provider types and implementing appropriate claim capture strategies, Covered Entities can ensure both the compliance and financial success of their 340B programs.

SunRx is here to help you simplify your 340B program administration and is a trusted 340B partner.

SunRx 340B solutions include: