Article 2: Billing Queue & Insurance Adjudication

Overview

Before any prescription order can be fulfilled, it must be billed and adjudicated through the patient's insurance. This article explains the billing queue and the adjudication process using Kroll.

Understanding the Billing Queue

The Billing Queue contains all billing items that have been created through Phox Entry and are awaiting insurance adjudication.

Accessing the Billing Queue

1. Navigate to the Billing section

2. View all pending billing items

3. Each item displays patient name, prescription details, and status

The Adjudication Process

What is Adjudication?

Adjudication is the process of submitting a prescription claim to the patient's insurance company to determine:

• Coverage eligibility

• Patient copay amount

• Insurance payment amount

Steps to Complete Adjudication

1. Select a billing item from the queue

2. Open Kroll (the pharmacy management system)

3. Bill the prescription in Kroll

4. Wait for adjudication to complete

5. Return to Phox and proceed with the order

System Message: "Please bill this prescription in Kroll before proceeding. Ensure that the adjudication is complete."

Billing Item Status

StatusMeaningPendingAwaiting adjudication in KrollAdjudicatedInsurance response received, ready to proceedRejectedInsurance claim denied, requires resolution

Important Considerations

Duplicate Order Prevention

The system automatically checks for existing orders:

• If an order already exists for the same prescription, you cannot create a duplicate

• View the order history to check the status of previous orders

• Completed (delivered) orders allow new orders to be created

One Order Per Patient Rule

Best practice is to maintain only one active order per patient at a time to:

• Prevent confusion

• Ensure accurate tracking

• Maintain inventory accuracy

Working with Kroll

Key Integration Points

1. Billing Items created in Phox must be processed in Kroll

2. Adjudication results from Kroll determine the patient's cost

3. Day supply information syncs between systems

Common Kroll Tasks

• Submit insurance claims

• Process prior authorizations

• Handle rejected claims

• Update patient insurance information

Troubleshooting

Claim Rejected

If an insurance claim is rejected:

1. Review the rejection reason in Kroll

2. Contact insurance if needed

3. Resubmit with corrections

4. Update Phox once resolved

Patient Not Found

If the patient doesn't appear in the billing queue:

1. Verify the billing item was created

2. Check if the order was already processed

3. Review the patient's order history

Quick Reference

ActionSystemPurposeCreate Billing ItemPhoxInitiate order processBill PrescriptionKrollSubmit to insuranceAdjudicateInsuranceDetermine coverage/costProceed with OrderPhoxContinue to payment collection

Next Steps

Once adjudication is complete, proceed to Article 3: Payment Collection & Day Supply Verification to learn about collecting patient payments and verifying prescription details.