Find answers to common questions about the Clinical Module—how it works, billing requirements, supported services, and more.
What is included with the Clinical Module?
- Clinical Workflows
- ECare Plans
- Medical Claims Submission
- Medical Claims Management and Tracking
Add-ons that work well with the Clinical Module
- Point of Care Testing, Vaccine, and Enhanced CPA’s
- Vaccine Module
Who can access the Clinical Module?
Pharmacies that have purchased Opportunities and the Clinical Module or a Premium Bundle will be able to access the products included in the module.
How are Clinical Workflows accessed?
A pharmacist can initiate a clinical workflow from the “Start a Service” button on the patient page. This is located under the Actions section of the Left Navigation. The “Start a Service” button can only be accessed if this has been granted access by the pharmacy administrator when the Clinical Module is purchased by the pharmacy.
How are eCare Plans accessed?
Premium pharmacies that have purchased the Clinical Module and linked their Outcomes account to PrescribeWellness (PW) will be able to access eCare Plan Templates. A pharmacist can initiate an eCare Plan by selecting a patient in Outcomes and choosing eCare Plans in the navigation (icon appears as medical bag).
How is Medical Billing accessed?
Premium clients that have linked their Outcomes account to PrescribeWellness can view the Medical Billing Status screen. Medical Billing claims submission and accounts receivable is an internal application managed via EZClaim. Access to EZClaim is not granted to clients directly at this time.
What medical billing services are offered in the clinical module?
The clinical module offers a comprehensive range of medical billing services, including revenue cycle management, accounts receivable, denials management, claims submission, and real-time patient eligibility and benefit information. These services help pharmacies efficiently manage their billing processes and ensure timely reimbursement.
Who/how does the Clinical workflow product get assigned to a NCPDP?
These are assigned on the backend of Outcomes. Currently this is hard coded at the center level, but the Outcomes team is working on feature enhancement to allow workflows to be added by state, policy, NCPDP, combinations and make it not tied to specific hard code.
How does support view if an NCPDP has the clinical workflow product on as well as which workflows are turned on for each store?
This is visible in Salesforce by accessing the client’s account. Information regarding this subscription will be loaded as a Module called Outcomes Clinical.
How does support view which users and workflows are permissioned to view clinical workflows?
The pharmacy administrator grants users at each location permission to access specific workflows. A pharmacist can see the workflows enabled for their location. However, if the pharmacist tries to start a workflow without the necessary permissions, they will encounter an error message stating, “Your pharmacy administrator must grant you access to perform this service.” In this case, the pharmacist will be unable to initiate the workflow. Support can view this information by impersonating the pharmacist's account.
Once I have the Clinical Workflow product and workflows permissioned, what can I see? What can I not see?
Once the workflows have been permissioned, a pharmacist will be able to “Start a Service” for that clinical workflow for the patient. Only workflows that are turned on for the location will be visible when “Start a Service” is selected. Users that do not have permission will see “Start a Service” but receive a message stating "Your pharmacy administrator must grant you access to perform this service".
If I subscribed to Clinical Workflows, will I see all services (workflows)?
A pharmacist will only see workflows that are turned on for their location(s).
How do I view all the available Clinical Workflows that Outcomes offers?
Outcomes currently offers the following national workflows: Medication Administration, Clinical Evaluation and Management, Diabetes Evaluation and Management, COVID-19 Point of Care Test and Treatment. The following workflows are available by state: Influenza Point of Care Test and Treatment, Strep Point of Care Test and Treatment, and Smoking Cessation. Please refer to the Outcomes website for a complete active list of live workflows.
How do I subscribe/turn on new clinical service workflows?
The pharmacy should reach out to their sales representative or account manager to inquire about turning on additional Clinical Workflows.
How do I subscribe/turn on new payers and services for medical billing?
The pharmacy should reach out to their sales representative or account manager to inquire about turning on additional payers. Outcomes will follow up with a form to gather the additional payer data to begin the implementation process.
How does the pharmacist determine the method of payment at the end of the workflow? (ex: medical billing, cash pay, clinical documentation only)
This is all dependent on the pharmacist’s scope of practice in the state and contracts between a payer and pharmacy. The clinical director will provide guidance to the pharmacist on which services are able to be medically billed vs patient cash pay vs clinical documentation only. If a pharmacist asks about this, please refer them back to their pharmacy administrator.
Why was I stopped in the workflow? (looked at state protocols, contraindications, etc.)
The clinical workflows have clinical decision support built in based on state or federal protocols to appropriately qualify or disqualify a patient based on eligibility requirements of the protocol. For example, a patient will be disqualified for COVID test and treat if their oxygen saturation if less than 94%, they have renal or hepatic impairment, or they have an allergy to Paxlovid. If the client would like to request a change to the workflow based on a policy update in their state, please contact us at 877-237-0050.
What types of reporting will I see for my completed Clinical Workflows?
The pharmacy administrator can pull reporting of clinical workflows across the pharmacies they are associated with. They can select the hamburger menu and select “Advanced Clinical Services” from the menu and click “Export Service History” where they can enter the date range of interest and download that report as an excel spreadsheet.
Why do I not see the Clinical Workflows with my MTM transactions?
While clinical workflows can be performed on the same patients that qualify for MTM services, they follow a different reporting structure so are not able to be pulled into legacy MTM reports currently.
Can the pharmacy technician or intern complete a Clinical Workflow?
Currently, workflows are only able to be completed by a pharmacist user. This may be adjusted in the future depending on client feedback. A tech or a pharmacist intern can enter medical insurance for the patient via the insurance drawer.
When do I need to add a patient? How do I add a service for a patient not already in Outcomes?
Patients can be manually added by selecting the “Create a patient” functionality at the top of the page next to the right of the patient search box. At the conclusion of adding a new patient, the pharmacist can then start a clinical encounter with them.
Adding patient medical insurance?
In the patient page, medical insurance can be added to a patient using the “Edit insurance” selection under the 3 dots to the right of the patient’s name. Insurance can also be added to the insurance drawer on the right side of the patient page.
What happens after I submit a workflow to go for medical billing?
When you submit a workflow for medical billing, our system will create a claim and send it to the patient’s insurance provider for payment. Payments for claims will be sent directly to your pharmacy or the location you’ve designated for receiving payments from the insurance provider. This process typically takes several weeks, from claim submission to payment by the insurance company. If any issues arise with the claim, our Outcomes team will handle them and will only contact you if additional information is required.
What do I do if the client has a specific medical billing question or a question regarding their claim?
When a medical billing question is received that requires further medical billing specialist support and research, please create a case in Salesforce to the Medical Billing queue. Please allow a 5-business day turnaround for this research to be completed.
How will I be informed about my claim’s information?
Customers that have linked their Outcomes account to a PrescribeWellness account have access to a medical billing status screen within the Outcomes system. This screen displays all claims that have been received and the status of the claim. By selecting Service History in the Left Navigation, then selecting Medical Billing, you can see the status of claims submitted, including payment information and whether the claim is received, submitted, processing, or completed with the payer. You can also export this information for up to the past 365 days (about 12 months), making it easy to keep records or perform further analysis.
How often are my claims submitted to the payer?
Currently, claims are submitted to the payer twice per week.
Are Clinical Workflows an MTM payable service?
No, clinical workflows are paid as medical claims, which are billed directly to the insurance carrier from the patient’s medical insurance policy.
Do you offer vaccine medical billing?
Yes, we offer vaccine medical billing for Rx30 or ComputerRx clients only. This service allows pharmacies to bill for reimbursement of Medicare Part B covered vaccines, including influenza, COVID-19, pneumococcal, and Hepatitis B. Additionally, pharmacies can bill for the reimbursement of the administration of these vaccines.
Are Clinical Workflow Medical Claims reported with MTM Claims?
No, Clinical Workflow Medical Claims are not reported with the MTM Claims and have their own reporting mechanisms through the Medical Claims status screen and Advanced Clinical Services screen.
Where can I view the status of my claims?
You can view the status of your claims through the status screen in the Outcomes system by selecting Service History on the left navigation, then selecting Medical Billing. This screen will provide comprehensive details on claim status, payment information, and more. Alternatively, you may also contact your insurance company directly to inquire about the status of your claims if desired.
What are the claim statuses displayed in the Medical Billing status screen and what do they mean?
There are four (4) statuses tracked for medical billing claims. New is the initial status applied when a medical claim is received for billing. This indicates to the pharmacy that the claim was received for medical billing, but the claim has not yet been billed. The next status is Accepted, which indicates that the claim has been submitted into the billing process within Outcomes. The claim is moved to a status of Processing when the claim is successfully submitted and is under review with the payer. The claim will move to a status of Adjudicated when the claim has completed processing with the payer. Adjudicated indicates the claim is paid, adjusted, or written off based on how the claim was processed by the payer. You can reference the claim value fields on the status screen for more information regarding how the claim was processed.
How long will it take for the insurance company to send payment?
The average processing time for insurance payments varies by payer but typically ranges around 30 days from the time of claim submission. This can vary based on the payer’s internal processing times and the complexity of the claim. If there is a patient responsibility due to a deductible, co-insurance, or co-payment, those collections are handled directly by your pharmacy. Outcomes does not provide a service for patient collections.