What an unverified claim actually costs you
The covered entity — not the pharmacy, not the TPA, not the software vendor — is strictly accountable for every contract-pharmacy 340B claim. When a claim is wrong, four things can happen, and multi-TPA networks make each more likely.
The failures HRSA finds
Diversion. A 340B-priced drug reaches a patient who is not eligible under the entity's encounter relationship. Duplicate discounts. A 340B-priced claim also collects a Medicaid rebate because carve-in/carve-out status was never reconciled against the Medicaid Exclusion File.
Fatal exception — blocked from the opinion Diversion finding Duplicate-discount exception open Repayment demand or program removal
Now layer the current environment on top: the post-Genesis patient-definition ruling is contested, the rebate-model pilot was vacated in February 2026, and 13 states passed new contract-pharmacy access laws in 2025 alone. Health systems running multiple TPAs across sites routinely apply inconsistent eligibility logic — putting millions of dollars in compliance-critical savings at risk, while HRSA audits hospitals at 10× the rate of manufacturers.
What you get: the Audit Package
One outcome, priced per audit or per audited claim — never hourly. Every term below is the same word we use in the package, the FAQ, and the operating dossier.
Eligibility Match
Every Audited Claim matched to an eligible encounter and priced against NDC/WAC, with a rule citation on every determination — testing 100% of contract-pharmacy volume, not a sample.
Compliance Lint
Deterministic Medicaid Exclusion File, GPO-prohibition, carve-in/carve-out, and pricing checks run as code, so a fixable exception never becomes an HRSA finding.
Duplicate-Discount Reconciliation
Every discrepancy against the Medicaid Exclusion File identified and resolved the compliant way, with a documented resolution note before delivery.
Certified Review
An Apexus-certified 340B expert and a pharmacist reviewer clear every contested-eligibility and low-confidence claim before it enters the opinion.
Exception Register
Every flagged claim, the specific rule it failed, and the remediation — the record an HRSA examiner asks for first.
Recapture File
Legitimately eligible claims your TPA logic missed, ready to submit for savings — never a claim we invented to inflate the number.
How it works
Intake → Normalize → Match & Test → Compliance Lint → Certified Review & Sign → QA Reconcile → Deliver. Humans hold the one commitment a model must never fake: the certified sign-off.
Connect your feeds
Read-only TPA accumulator export, EHR encounter data, dispensing and purchasing records, and Medicaid carve-in status — into a secure, least-privilege intake under a signed data agreement.
We match & test
Every claim is matched to an encounter, priced against NDC/WAC, and tested against the Medicaid Exclusion File, GPO-prohibition, and sampling-integrity rules — no claim skipped, no volume sampled unless you choose it.
Compliance Lint runs
Deterministic rules run as code; every duplicate-discount discrepancy is drafted for resolution before it becomes a finding.
Certified Review clears the queue
An Apexus-certified expert and a pharmacist reviewer judge contested-eligibility and low-confidence claims — nothing auto-clears into the opinion.
We sign; you stay of record
The certified reviewer signs the Signed Independent Opinion within scope. You remain the covered entity of record to HRSA — we never certify on your behalf.
Deliver & defend
The Audit Package — opinion, Exception Register, Recapture File, audit trail — ships to your authorizing official, ready if an examiner asks for it.
Pricing
Priced per audit or per audited claim — anchored to the program-continuation risk you remove, never to labor hours. Never hourly; recapture-share only after legal review, never the sole model.
- Sample of your contract-pharmacy claims reviewed
- Your likely exception cohorts & recapture range, named
- One sample Exception Register page
- Signed Independent Opinion on contract-pharmacy eligibility
- Exception Register + Recapture File
- 100%-of-volume testing, not sampled
- Delivered in three weeks
- Ongoing eligibility & duplicate-discount monitoring
- Always-audit-ready Exception Register
- Reduces your next full-audit rate
Also: Full Annual Independent Audit at $25,000–$60,000 per entity/year (eligibility + diversion + duplicate-discount + GPO-prohibition + pricing scopes) · per-audited-claim add-on at $0.03–$0.12/claim for full-population testing · rush under two weeks, +$3,000–$8,000 per audit. Never hourly.
Examiner-Attributable-Finding Guarantee & out-clause
If HRSA issues a finding attributable to our testing on a claim we certified as clean, we re-audit the affected scope at no charge and credit your next audit. The Continuous-Integrity Subscription is month-to-month with 30-day notice — cancel anytime and keep every Audit Package already delivered. We do not guarantee any HRSA determination or program-continuation outcome; those belong to HRSA and your counsel. We never sell managed-services/TPA operation and an independent audit to the same entity for the same period — that would void the independence the opinion depends on.
Proof
We launched this desk recently. Rather than invent testimonials or numbers, we show you exactly where real results will appear as the first audits ship.
Founding-cohort audit results
Examiner-defensible clearance rate, certified-reviewer minutes per audit, and dollars recaptured, from our founding entities.
Named entity stories
Covered entities who moved from sampled hourly consulting to 100%-of-volume, certified-signed audits — with their permission and real figures.
Clean-audit record
HRSA outcomes on serviced files as audit cycles complete — our target is zero examiner-attributable findings on audits we sign.
Questions program managers and compliance officers ask
Isn't this just what our TPA or capture software already does?
Do you certify or report to HRSA on our behalf?
Can you also run our TPA or capture software?
How do you handle claim and encounter data?
What changed after the Genesis ruling and the vacated rebate-model pilot?
Do you test every claim or just a sample?
How fast is an audit?
Request a free Diversion & Duplicate-Discount Risk Scan
Tell us a little about your program. With your consent, we review a de-identified sample of your contract-pharmacy claims and send back your likely exception cohorts and an estimated recapture range — named — plus one sample Exception Register page. Next step is a capped Contract-Pharmacy Eligibility Integrity Audit.
After you submit: we reply within two business days to open a secure folder under a signed data agreement. We ask only what the scan needs — everything else comes later in the workflow.
The licensing boundary, in plain language
We test contract-pharmacy 340B claims and draft a signed independent audit opinion from the facts you provide and current HRSA program-integrity guidance. We match claims to encounters, resolve pricing, run the Compliance Lint, and reconcile the Medicaid Exclusion File. An Apexus-certified expert and a pharmacist reviewer sign the opinion within our scope. We do not make your eligibility or carve-in policy decisions, opine on contested legal questions, act as your Contract Administrator, or guarantee any HRSA determination or program-continuation outcome.
[PLACEHOLDER] First-cohort audit turnaround — our per-audit price is $12,000-35,000 with a three-week target cadence. The real measured turnaround appears here once the first founding entities complete a full audit cycle.
[PLACEHOLDER] First covered-entity reference — added only with a named entity's written permission. ClaimClear never invents a testimonial or an entity name.
[PLACEHOLDER] Total 340B claims independently tested to date — a live, auditable count once real audits have been delivered and signed, never estimated.