Accident and injury claims do not behave like a retail script. There is a carrier instead of a PBM, a form instead of a switch, and a deadline that decides whether the fill was worth doing. We run New York and New Jersey, with more states coming.
The auto carrier pays for prescriptions arising from the accident, not the patient's health plan and not a PBM. The claim is only as good as the paperwork behind it.
- Confirm the carrier, claim number, adjuster and date of loss before the script is filled, not after the bill is rejected
- Take the assignment of benefits, so the pharmacy is billing in its own right
- Prepare and submit the NF-3 with the dispensing detail the carrier will ask for
- Answer verification requests inside the window instead of letting the clock run
- Work the NF-10 denial: read the reason, fix what is fixable, and resubmit
- Build the arbitration packet when the carrier will not pay a payable claim
FormsNF-3NF-AOBNF-10
Personal Injury Protection is primary for accident-related prescriptions in New Jersey. The gate is the treatment plan, and missing it is what turns a covered fill into a write-off.
- Confirm PIP coverage and the claim before dispensing, including which carrier is actually primary
- Handle decision point review and precertification where the plan requires it
- Submit the Attending Provider Treatment Plan with the supporting detail
- Work denials and underpayments rather than filing them
- Prepare the PIP arbitration submission where the carrier will not resolve it
FormsAPTPDecision Point Review
The pharmacy dispenses against a personal injury settlement and is paid when the case resolves. The money is real, but it arrives late and only if the paperwork exists.
- Paper the lien or letter of protection with the attorney before the balance grows
- Keep a per patient, per case ledger so the balance is never reconstructed from memory
- Keep the case status current with the firm rather than waiting to be told
- Present the balance at settlement, with the dispensing record behind every line
- Reconcile what actually arrives against what was presented
FormsLienLetter of protection
04Workers' Comp
New YorkNew Jersey
A work injury puts the prescriptions on the comp carrier. The rules are their own: a fee schedule, a carrier that objects in writing, and a board behind it.
- Confirm the claim, the carrier and whether the injury is accepted or contested
- Bill to the comp fee schedule rather than to a retail price nobody will pay
- Answer the carrier's objection on its own terms and within its own timeline
- Escalate to the board when the carrier will not pay a payable claim
- Track the long tail, because comp balances outlive the fill by months