The rejected claim gets fixed before the line behind the register grows.
Every pharmacy that calls about a rejected or pending claim gets an accurate, real-time answer from EHVAhealth: the reject reason, what fixes it, and an override when one applies, without a hold queue and without pulling your claims team off harder work.
The reject codes never stop coming
A rejected claim at the counter is the single most repeated call a PBM help desk fields: refill-too-soon, prior claim conflicts, missing prescriber NPI, quantity limits. Each one pulls a trained tech away from harder adjudication work while a patient waits. EHVAhealth takes the whole line.
High volume, low variety
The same handful of reject reasons, thousands of times a month. Built to resolve them cleanly and consistently.
Your best people, tied up
Help desk techs spend their day reading reject codes aloud instead of handling the calls that need judgment.
Pharmacy relationships strained
Long holds with a patient standing at the register are the top complaint pharmacies have about PBMs. First-call answers fix it.
Authenticate, look up, resolve, log
Every call follows the same disciplined path, connected live to your claims switch so the answer reflects the current adjudication.
Authenticate the caller
Verify the pharmacy and the specific member and claim securely before any detail is shared.
Pull the claim in real time
Query your claims switch or adjudication platform live, so the reject reason reflects the current transaction.
Explain the fix
Reject or paid status, NCPDP reject codes translated into plain language, and what resubmission or override applies.
Apply or route the override
Apply an override within your configured rules, or hand cases that need judgment to your team with full context attached.
Everything a pharmacy claims line needs
Real-time claim status
Current paid, rejected, or captured status straight from the switch.
NCPDP reject codes, explained
Reject codes translated into the specific fix a pharmacy tech can act on.
Overrides within your rules
Refill-too-soon, vacation supply, and lost-medication overrides applied to your configured limits.
Retail, mail, and specialty
One line across every pharmacy channel, not a separate queue for each.
Every call QA-scored
Quality reviewed on all calls, with the scores reported back to you.
Dashboards and reporting
Volume, resolution, and override rates you can see, not guess at.
Failover to your team
If anything interrupts service, calls route to your standard handling. No pharmacy is stranded.
Connects to your switch
Reads live from your claims switch or PBM platform through its API.
PHI kept in bounds
Protected data stays inside an access-controlled, audited environment.
Hear what a pharmacy claims call actually sounds like
Real handling, on your reject codes and override rules, before you commit to anything.
Fewer holds, cleaner calls, lower cost
Call resolution
Answer speed
Onboarding
Quality coverage
Claim data stays protected
Every pharmacy claims call touches PHI, so the whole workflow runs inside a controlled, audited environment. We give your compliance team the documentation they need before the first call is answered.
Pharmacy claims, answered
Does this connect to our claims switch?
Yes. EHVAhealth reads live from your claims switch or PBM adjudication platform through its API, so callers hear the current status, not a stale copy. If your system lacks an API, our team finds an alternative path during onboarding.
Can it apply overrides itself?
Within the rules you configure, yes: refill-too-soon, vacation supply, and lost-medication overrides are common ones we automate. Anything outside those rules routes to your team with full context.
Does it cover retail, mail, and specialty pharmacy?
Yes, across every channel on a single line, rather than forcing pharmacies into separate queues by claim type.
How is protected health information handled?
The workflow is HIPAA compliant and runs under a signed BAA. Data stays in an access-controlled, audited environment, and our controls are mapped to the HITRUST CSF. Your compliance team can request the full security package before go-live.
What happens when a call needs a person?
Escalation rules are set with you. When a caller asks for a human or a case falls outside scope, the call hands off cleanly to the right person or queue, with the context preserved.
Handle the rest of the line too
EHVAhealth in production
Acuity Group: 81% automated
Claims, eligibility, and benefits calls answered end to end for a TPA covering 16,471 lives.
Read the case studyCareFactor: 90% autonomy
Benefits and claims calls answered from plan documents and EOBs, 24/7, for 30,000 lives.
Read the case studyWellNet Healthcare
A TPA running Five9 and Salesforce selects EHVAhealth for its provider calls.
Read the announcementTake pharmacy claims calls off your team's plate
No pitch. We will show you real claims handling built for your switch and your override rules.