This article introduces medical billing in MedMe. It explains when a service is billed to the patient's medical benefit, the enrolments a pharmacy needs before its first claim, what to check before every claim, and the most common mistakes new pharmacies make.
Table of Contents
Overview
Medical billing is the process of submitting claims for clinical services, such as assessments, test-and-treat, chronic care visits, and some vaccines, to a patient's medical insurer for reimbursement. Unlike pharmacy claims, which are adjudicated in real time at the point of sale, medical claims are submitted after the service is delivered, using a standard professional claim format (CMS-1500 / 837P) and clinical codes (ICD-10 diagnosis codes and CPT / HCPCS procedure codes).
Payers, including Medicare, Medicaid, and commercial insurers, review each claim and pay or deny it based on coverage, eligibility, and documentation.
MedMe lets pharmacy teams create, submit, and track medical claims directly in the platform. The MedMe RCM team monitors the pharmacy's claims and helps resolve rejections and denials.
Medical Benefit vs Pharmacy Benefit
Most patients have two kinds of coverage, and each one pays for different services. Knowing which benefit covers a service before it is provided prevents most denials.
Benefit | What it usually covers | How it is billed | When the outcome is known |
Medical benefit | Clinical services a pharmacist performs, such as assessments, point-of-care testing, test-and-treat, and chronic care visits, and vaccines covered as a medical service (for Medicare patients: flu, COVID-19, pneumococcal, and hepatitis B vaccines under Part B) | A professional medical claim, created and submitted in MedMe | Days to weeks later, when the payer adjudicates the claim |
Pharmacy (drug) benefit | Prescription medications and most other vaccines (for Medicare patients: Part D vaccines such as shingles, RSV, and Tdap) | An NCPDP claim through the patient's PBM, in the pharmacy management system | In real time, at the point of sale |
Reminder: Coverage for pharmacist-provided services varies by payer, plan, and state. When in doubt, verify eligibility before the visit and check with the MedMe RCM team.
Tip: For a worked example of choosing the right benefit, see Billing Medicare Part B for Flu and COVID-19 Vaccines in MedMe.
Before Your First Claim: Enrolments
A pharmacy has to be set up with each payer before that payer will accept its electronic claims. MedMe completes this setup with the pharmacy during onboarding.
NPIs: the pharmacy's Type 2 (organization) NPI, and a Type 1 (individual) NPI for every pharmacist who provides billable services. These are used as the Billing Provider and Rendering Providers on claims (see How to Manage Providers on Claims in MedMe).
Payer enrolment: some payers require the pharmacy to be enrolled with, or credentialed by, the payer before they pay for services. For Medicare, this is Medicare enrolment through PECOS with an active PTAN.
EDI enrolments: the electronic connections that let MedMe exchange claims and responses with each payer. They are set up per payer and per transaction type, as shown below.
EDI enrolment | What it allows | If it is not complete |
Claims (837P) | Submitting claims electronically to the payer | Claims sent to that payer are rejected |
Eligibility (270 / 271) | Checking coverage with Verify on the patient profile. Only some payers require a separate enrolment for eligibility checks. | Eligibility checks with that payer fail, often with a message that the provider is not on file, even when the patient has active coverage |
Remittance (ERA / 835) | Receiving the payer's electronic payment and adjustment details, shown on a claim's Remittances tab | Payment details are not received electronically, so they do not appear on the claim in MedMe |
Warning: Do not submit claims to a payer until the pharmacy's EDI enrolment with that payer is complete. Claims sent to a payer without a completed enrolment are rejected. Check with the MedMe RCM team to confirm which payers are ready before billing them.
Please Note: Each payer is enrolled separately, and approval times vary by payer. A pharmacy can be ready to bill one payer while enrolment with another is still in progress.
The Billing Workflow in MedMe
Collect the patient's medical insurance. Patients can enter it when booking, and pharmacy teams can add it on the patient profile, including by scanning the insurance card. See How to Add and Manage a Patient's Insurance in MedMe.
Verify eligibility for the date of service. See How to Check Insurance Eligibility in MedMe.
Provide the service and complete the documentation for the appointment. The documentation supports the codes that are billed.
Create and submit the claim from the appointment's Claims card. MedMe prefills the codes from the pharmacy's claim template. See How to Create and Submit a Claim in MedMe.
Track the claim on the Claims page and act on rejections or denials. See How to Use the Claims Page in MedMe and Understanding Claim Statuses and Actions in MedMe.
Verify Before You Submit
Most rejections are caused by information that could have been checked before the claim was sent. Before selecting Submit for Billing, confirm that:
The pharmacy's EDI enrolment with the payer is complete.
The insurance on the claim is the patient's medical insurance, not a pharmacy benefit card (for example OptumRx, CVS Caremark, or Express Scripts).
The insurance is Active, and an eligibility check returned active coverage for the date of service.
The subscriber ID, name, and date of birth match the insurance card exactly.
The patient profile has the patient's sex, date of birth, and complete address.
The service is covered by the medical benefit (see Medical Benefit vs Pharmacy Benefit above).
The codes match the service provided, and the Rendering Provider and Billing Provider are correct.
The appointment has not already been billed on another claim. Check the appointment's Claims card.
Warning: If the patient is likely to pay out of pocket because of a deductible, copay, or coinsurance, and subject to applicable state requirements, obtain the patient's explicit consent before collecting payment. Collect payment only through a secure, PCI-compliant system, such as the pharmacy management system. MedMe does not store credit card information.
Common Mistakes to Avoid
Mistake | What happens | How to avoid it |
Submitting to a payer before EDI enrolment is complete | The claim is rejected | Confirm with the MedMe RCM team which payers are ready |
Entering a pharmacy benefit (PBM) card as the medical insurance | The claim is rejected or denied | Check the card; pharmacy benefit cards usually show Rx BIN and PCN numbers |
Billing Original Medicare for a patient with a Medicare Advantage plan | The claim is denied (CO-109) | Ask whether the patient's Medicare is through a private plan, and check the card |
A name, date of birth, or member ID that does not match the payer's records | Eligibility fails and the claim is rejected | Copy the details exactly from the card and verify eligibility |
Skipping the eligibility check | Coverage problems are only found after the claim is rejected or denied | Verify every insurance before the visit |
Billing a pharmacy-benefit service as a medical claim | The claim is denied | Check which benefit covers the service before billing |
Billing the same service twice | The claim is denied as a duplicate | Check the appointment's Claims card before creating a claim |
Leaving rejected or denied claims too long | The claim passes the payer's timely filing limit and can no longer be paid | Use the Timely filing filter on the Claims page and act promptly |
Support from the MedMe RCM Team
Pharmacies billing through MedMe are supported by the MedMe RCM team. The team:
Monitors the pharmacy's claims and helps resolve rejections and denials.
Confirms which payer enrolments are complete.
Sets up claim templates and fee schedules for the pharmacy's services.
Answers billing and coding questions.
The articles in this collection explain each step in MedMe, so pharmacy teams can assess and resolve issues on their own. For support at any point, contact the MedMe RCM team.
Conclusion
Before billing, make sure the pharmacy's enrolments are complete for each payer, collect and verify the patient's medical insurance, and confirm the service belongs on the medical benefit. Then document the encounter, create and submit the claim in MedMe, and track it on the Claims page, with the MedMe RCM team available to help at every step.
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