Change Healthcare (CHC), formerly Goold Health Systems (GHS), the Pharmacy Benefits Administrator for the ODM Fee-for-Service (FFS) program, is responsible for the operation of the pharmacy claims review program. CHC provides services that include: analysis of all paid claims through claims review mechanisms, recoupment of overpayments, educational services to enrolled ODM FFS pharmacy providers, and fraud detection and deterrence. All pharmacies enrolled with the ODM FFS program are subject to claims reviews. Please note, the information contained here does not pertain to any policies and/or procedures for the ODM managed care plans.
Claims review satisfies the federal requirements to help protect against fraud, waste, and abuse (FWA). Additionally, claims review provides pharmacies education in correct billing practices. Any paid claims that do not fully comply with all requirements or ODM FFS policies are subject to recoupment.
ODM FFS pharmacy providers are subject to statutorily mandated elements for prescriptions and drug orders. The ODM will recoup payments on claims associated with prescriptions or drug orders if the mandated elements are missing.
For additional claims review information, refer to the ODM Pharmacy Claims Review Provider Manual January 2023.
You may also email the Pharmacy Claims Review Department at OHclaimsreviewdept@changehealthcare.com.