Manually pulling in rejected and qualified claims in the TPA database is a critical step in capturing eligible 340B savings that may have been missed due to unmatched prescription data. Claims can fail to match automatically to an EMR (Electronic Medical Record) or ERX (Electronic Prescription) record due to discrepancies in provider documentation, timing issues, or data entry errors. By reviewing and manually adjudicating these claims, covered entities (CEs) can identify encounters that still meet 340B eligibility requirements but were not captured through automated matching. This practice ensures the entity maximizes its 340B benefit while maintaining program compliance.

Furthermore, this manual reconciliation process supports stronger audit preparedness and data integrity. By documenting the rationale for qualifying claims and ensuring proper linkage to eligible encounters, CEs can provide a defensible audit trail. It also helps identify patterns in rejected claims that may point to workflow or system issues, allowing for targeted improvements. Ultimately, consistently reviewing and processing unmatched claims manually helps optimize program performance while upholding the accuracy and accountability essential in 340B operations.

Pillr Health is proud to share that we are now officially registered as a Medicare Transaction Facilitator (MTF) Third-Party Support Entity (TPSE) with the Centers for Medicare & Medicaid Services (CMS).

This milestone underscores Pillr Health’s role as a trusted partner in helping covered entities, pharmacies, and manufacturers navigate the evolving requirements of the Inflation Reduction Act (IRA) Maximum Fair Price (MFP) program.

Our technology and compliance platform is built to simplify complex processes—delivering seamless support across effectuation and reconciliation. In addition, Pillr Health has completed setup with the National Council for Prescription Drug Programs (NCPDP) as a Pharmacy Remit, Reconciliation, and Payment Vendor, further streamlining both operational and financial processes.

We remain committed to advancing solutions that empower healthcare organizations to thrive in today’s rapidly changing landscape.

 In today’s 340B environment, every claim counts. With increased oversight, tighter margins, and growing manufacturer restrictions, covered entities need to maximize their 340B savings by capturing every eligible claim. One often-overlooked opportunity lies in understanding and monitoring disqualified claims.

These are claims that, for one reason or another, didn’t qualify for 340B qualification—but could have. Rather than accepting disqualifications at face value, covered entities should treat these claims as signals for action. Below is a guide to reviewing and correcting disqualified claims, in collaboration with your third-party administrator (TPA), to ensure you aren’t leaving savings on the table.

Start by Working with Your TPA

Your TPA plays a critical role in filtering and qualifying claims for 340B eligibility, and their system often holds valuable insight into why claims are being disqualified. Start by requesting a disqualified claims report from your TPA – not all TPAs provide this proactively.

Having this visibility gives your team the opportunity to dig deeper and identify patterns or errors that can be corrected moving forward.

Key Areas to Review in Disqualified Claims

Once you have the disqualified claims report in hand, focus on the following categories

1. Pricing Fall-Offs

Sometimes a claim qualifies clinically but is disqualified due to pricing data not being available or applied correctly. This can occur if 340B pricing is delayed or not loaded.

Work with your TPA and wholesaler to determine why pricing was missing and whether those claims can be retroactively captured or reprocessed.

2. Eligibility Window Issues

Your 340B program eligibility depends heavily on encounter data and timing. Many disqualified claims stem from:

• Providers who are 340B-eligible but whose encounters fall outside your configured eligibility window

• Missing or delayed eligibility files

Solutions to consider:

• Expand the eligibility window to capture a broader range of legitimate encounters

• Audit your eligibility files and submission process to ensure complete and timely data

Even small configuration changes here can have a major impact on claims capture.

3. Medicaid Mismatches

Medicaid carve-in/carve-out status can be a common source of disqualification—especially if payor information isn’t clearly defined. Disqualified Medicaid claims may happen if:

• The claim is incorrectly flagged as Medicaid, when it’s a Medicare or a Commercial plan

• You don’t have the correct BIN/PCN or Group ID listed in your TPA configuration

• Payors are not properly mapped or blocked/unblocked in the system

Take time to confirm your payor list and cross-reference it with what the TPA sees. Ensure all “should-be-qualified” payors are being handled correctly.

4. Data Feed or Switch Issues

In some cases, the problem isn’t qualification logic—it’s data availability. If your TPA isn’t receiving a complete or accurate feed of your claims data, disqualification can happen simply due to missing context.

Things to watch for:

• A sudden drop in 340B-eligible volume that doesn’t align with patient or script trends

• Claims from certain providers or locations missing consistently

• Switch issues that prevent prescription information from being transmitted

If these patterns emerge, engage with your pharmacy, switch vendor, or EMR to ensure full data is being transmitted.

Make It a Routine Process

Disqualified claims review shouldn’t be a one-time effort. It should be part of your monthly or quarterly monitoring process. A regular review process can help you:

• Identify technical or systemic issues early

• Adjust configurations as your program evolves

• Improve your 340B capture rate steadily over time

Final Thoughts

340B compliance will always be critical—but optimization is equally important. Disqualified claims represent real dollars and missed opportunities. By partnering with your TPA, auditing your program setup, and being proactive with your data, you can recover those claims—and more importantly, prevent future losses.

Remember, in today’s 340B world, every claim matters. Don’t let yours slip through the cracks.