What does a third-party payer assess before approving a claim?

A third-party payer evaluates the patient's medical history and insurance coverage as a critical part of the claims approval process because this information helps determine the appropriateness of the claim. The patient's medical history ensures that the prescribed medication is suitable for their specific health conditions, while the insurance coverage verifies whether the medication is included in the patient's benefits. This assessment ensures that the payer is aligned with clinical guidelines and the terms of the insurance policy, ensuring both the appropriateness of care and financial responsibility.

In contrast, while factors like the pharmacy's compliance record may influence the relationship with the payer over time, it is not a primary consideration for individual claim approval. Similarly, the prices of medications are typically established and agreed upon through contracts between the pharmacy and the payer, rather than being assessed on a claim-by-claim basis. The pharmacy's location and facilities might be relevant to overall service quality or operational capabilities, but they do not directly impact the assessment of a claim with respect to the patient’s eligibility and medical justification for the medication prescribed.