Empowering Pharmacies for Growth and Patient Care
The Outcomes Clinical Module is a comprehensive solution designed to help pharmacies manage clinical workflows, submit medical claims seamlessly, and maximize reimbursement for advanced clinical services. By leveraging this module, pharmacies can expand their service offerings, improve operational efficiency, and unlock new revenue streams—all while enhancing patient care.
Why It Matters
Pharmacies today are navigating shrinking reimbursement rates and an increasing demand for patient-centric services. We are committed to supporting pharmacies by providing a solution that helps them thrive in this evolving landscape. The Clinical Module empowers pharmacies to diversify their revenue streams by offering billable clinical services. With our robust claims submission and revenue cycle management support, we help pharmacies stay competitive, improve financial performance, and continue delivering high-quality patient care.
Training Videos:
COVID-19 Clinical Workflow Demo
Influenza POC Clinical Workflow Demo
Medication Administration Workflow Demo
Diabetes Evaluation Management Workflow Demo
Tobacco/Smoking Cessation Workflow Demo
Clinical Evaluation Management Workflow Demo
Key Features
- Clinical Workflows: National and state-specific workflows to support pharmacy-led services like Point-of-Care Testing, Diabetes Management, and Smoking Cessation.
- eCare Plans: Standardized documentation to enhance quality reporting and care coordination.
- Medical Claims Submission: Automated claim submission to payers for eligible clinical services.
Note: A payer contract is required for medical billing.
- Revenue Cycle Management: Comprehensive support for claims tracking, denial management, and payment reconciliation.
- Medical Benefits Verification: Real-time eligibility checks to confirm patient coverage before service delivery.
Clinical Workflow Capabilities
This section provides a high-level overview of each clinical workflow. These workflows support pharmacists in providing simple, quick clinical decision-making, aligned with their state or company-defined protocols.
How It Works
1. Access:- Pharmacists log into the Outcomes platform.
- They select the patient and initiate “Start a Service” and choose the appropriate workflow.
- Each workflow provides structured questions to guide the pharmacist through patient evaluation, ensuring eligibility based on state protocols.
- The workflow documents medical history and disqualifying factors.
- If qualified, the workflow suggests treatment options.
- Pharmacists can choose from three options at the conclusion of the workflow:
2. Cash Pay (equivalent to documentation only)
3. Submit for Medical Billing
Point of Care Test and Treat Clinical Workflows
Point-of-care test and treat (POCT) workflows allow pharmacists to evaluate, test, diagnose, and treat patients. Initial and follow-up encounters are available. Current POCT Workflows include:
- COVID-19 Testing and Treatment – National workflow available.
- Influenza (Flu) Testing and Treatment – State-specific workflow
- Strep Testing and Treatment – State-specific workflow
Medication Administration Workflow
The Medication Administration workflow allows pharmacists to document and manage the administration of long-acting injectable medications. This workflow supports enhanced clinical services, ensuring accurate records and enabling billing of time for evaluation and management.
Clinical Evaluation and Management Workflow
The Clinical Evaluation and Management workflow supports pharmacists in conducting comprehensive patient evaluations. This workflow is used for managing chronic conditions and conducting routine health assessments and is intended to be flexible to meet the needs of a variety of patient conditions.
Diabetes Evaluation and Management Workflow
This workflow is designed to help pharmacists manage patients with diabetes by facilitating regular evaluations and treatment adjustments.
Smoking/Tobacco Cessation Workflow
The Smoking Cessation workflow supports pharmacists in guiding patients through tobacco cessation programs, providing counseling, and prescribing cessation aids.
eCare Templates Capabilities
eCare Plan is an interoperable standard that allows pharmacy technology providers to have a common method of exchanging information related to care delivery, including patient goals, health concerns, active medication list, drug therapy problems, laboratory results, vitals, payer information, and billing for services. Outcomes offers an eCare Plan template and is an approved partner of CPESN, and Medication Therapy Management (MTM) template for medical billing to Michigan Medicaid.
How It Works
- Access:
- Pharmacies must have a PrescribeWellness account, and the PW account must be linked to their Outcomes account.
- Pharmacists log into the Outcomes platform.
- Select the patient and choose eCare Plans in the navigation (icon appears as medical bag).
- The pharmacist selects and completes the template for the visit.
eCare Plan Template
The eCare Plan is designed to provide electronic documentation of patient encounter information with a standardized method to exchange data. The eCare Plan enables pharmacist-led interventions, driving better patient outcomes by enabling pharmacists to work with patients to set goals and monitor progress over time.
MTM Medical Billing Template
Medication Therapy Management (MTM) Medical Billing is a type of eCare Template that focuses on completion of MTM services for billing to the patient’s medical insurance for reimbursement. MTM Medical Billing is available for Michigan-based pharmacies that are contracted with Michigan State Medicaid.
Vaccine Medical Billing Capabilities
Vaccine medical billing is the current product-based billing solution available within the Clinical Module. This capability allows pharmacies to bill a patient’s medical insurance for the vaccine and the administration of the service.
- This feature enables pharmacies to bill medical insurance for vaccines and administration, ensuring pharmacies are reimbursed appropriately for providing immunization services.
- It simplifies the billing process for pharmacies by integrating directly with the PMS (currently Rx30 and CRx only)
- Currently, billing is limited to Medicare Part B claims for pharmacies but could be expanded to other payers.
How It Works
1. Access:- Pharmacies using Rx30 or CRx PMS enter a vaccine fill as they normally would.
- During implementation, a specific plan code (026183) is setup within the PMS.
- When the plan code 026183 is applied to the vaccine fill, it designates the claim should be submitted for medical billing.
- The claim information is received via a nightly data feed into Outcomes.
- Claims are submitted weekly to patient medical insurance for processing.
- Claims payment is sent directly to pharmacies by the health insurance.
Medical Billing Capabilities
The Clinical Module includes features for submitting medical claims from Clinical Workflows and Product-based billing. This streamlines billing and ensures pharmacies can maximize revenue for provided services. Key features include:
- Automated medical claims generation from completed clinical workflows.
- Bi-weekly claim submission to medical insurance (Monday and Thursdays)
- Real-time eligibility verification and benefits check of patient insurance – ensuring up front collection ability at the pharmacy.
- Creation of 835 medical claims file sent to the patient’s medical insurance for payment.
- Payments made directly to the pharmacy from the insurance provider.
- The timeline for reimbursement can vary significantly depending on the payer. In some cases, pharmacies may receive payment as early as 10 days, but in other cases reimbursement is closer to 30-45 days. Outcomes strives for timely filing of medical claims to ensure faster pharmacy reimbursement.
The Clinical Module also supports ongoing management of medical claims, including reimbursement, denials, corrections, and appeals.
Key features include:
- Revenue Cycle Management (RCM) as a service.
- Monthly financial reporting of claims information for pharmacies.
- Claims follow-up and denials management to ensure claims are processed and paid.
- Accounts receivable oversight.
How It Works
- Access:
- Claim status screen is available for Vaccine medical billing clients and Outcomes premium clients.
- Pharmacies must have a PrescribeWellness account, and the PW account must be linked to their Outcomes account.
- SFTP site access is granted to provide monthly financial reports of claim information.
Support and Guidance
Once your contract is signed, you will receive a welcome call within one business day to review onboarding, discuss products and timelines, and address any initial questions. You will then be scheduled for a pre-installation session to gather all necessary data, confirm your payer and clinical services list, complete fee schedule templates, validate payer IDs and Service Type Codes (STCs), and finalize billing forms.
Following pre-installation, you will schedule installation and onboarding, where we set up medical billing using your billing data and submit required Electronic Data Interchange (EDI) enrollments for payers. Since some payers require additional processing time, we will guide you through this step to ensure a smooth transition.
Once your setup is complete, you will review training materials and then have an activation call to finalize the onboarding checklist. On your launch date, your pharmacy administrator will enable access for pharmacy users.
After going live, you will receive:
- 90 days of claims oversight to monitor performance and ensure successful reimbursement.
- Live phone support for any questions or technical issues.
- Ongoing training and growth opportunities to help you maximize the Clinical Module’s potential.
Training & Support Resources
Clinical Support:
Hours of Operations: Monday-Friday 7AM –7PM CT
Phone: 877-237-0050
Email: premium@outcomes.com
How to Get Started
- Interested in learning more? Fill out the form on this page to connect with a member of our team for a personalized consultation.
With the Clinical Module, you can expand your pharmacy’s services, bill with confidence, and drive sustained profitability. Ready to transform your clinical operations? Let’s talk!