CONFIDENTIAL AND PROPRIETARY
Results and Appeals
Walgreens Health Initiatives or its delegate shall furnish the pharmacy with the results of audit findings. The pharmacy will have the time set forth in the audit findings notice to appeal audit discrepancies. During the appeal period, the pharmacy may provide documentation to support or justify the identified discrepant audited claims. Requests for pharmacy audit appeals will be reviewed according to Walgreens Health Initiatives’ audit guidelines and the provisions contained within the Pharmacy Network Agreement. Failure by a pharmacy, as determined by Walgreens Health Initiatives, to respond to initial audit results or to provide appeal documentation during the established appeal period may result in suspension of payment or removal from the network at Walgreens Health Initiatives’ discretion. False or fabricated documentation will result in chargebacks and the possible suspension of payment and/or removal from the network.
MedMonitor® Complete is a medication utilization evaluation clinical tool that both protects patients from potential adverse medication events and enhances their quality of care. By integrating and monitoring prescription and medical histories, our MedMonitor program offers a view of the whole health picture and is designed to prevent costly and dangerous adverse medication events.
The ultimate goal of MedMonitor is to create long-term, outcomes-oriented benefits by reducing or eliminating the risk for unnecessary healthcare utilization (e.g., hospitalizations) by optimizing medication therapies.
MedMonitor utilizes a state-of-the-art operating system that integrates medical claims with prescription claims to identify patients at risk for dangerous and expensive medication-related problems and medical outcomes. Our operating system contains over 1,400 conflict edits designed to detect patterns of overutilization and/or abuse, underutilization and/or noncompliance, therapeutic duplications, drug-drug interactions, medication-disease interactions, drug-age interactions, and gaps in therapy. Traditional retrospective drug utilization review (RDUR) and medication therapy management (MTM) programs are the foundation of utilization management.
MedMonitor Complete takes it to the next level with a winning combination of two components, MedMonitor®24 which is the branded name for our enhanced RDUR program, and MedMonitor®XR the branded name for our MTM program.
Every Prescription, every daySM.
MedMonitor®24 is an enhanced Retrospective Drug Utilization Review (RDUR)
Walgreens Health Initiatives – Pharmacy Manual