Pharmacy revenue starts
before the claim.
RxAI validates every prescription against payer rules, formularies, prior authorization requirements, step therapy logic, and FDA indication data. The system runs in under five seconds and exits every prescription with one clear decision and one clear owner.
Most pharmacy denials are created long before billing ever sees the claim.
Patient Access Origin
The root cause of most denials lies in the initial patient access and intake process, long before a claim is generated.
Revenue at Extreme Risk
By the time a claim is rejected, the pharmacy has already incurred the cost of the medication and the labor to dispense it.
Not a Billing Failure
The denial is rarely a formatting failure. It's a clinical or administrative mismatch between the prescription and the payer's rules.
A decisioning layer that sits ahead of the claim.
RxAI evaluates every prescription against payer rules, formularies, prior authorization requirements, step therapy logic, and REMS indicator data.
The system runs in under five seconds and returns every prescription with one clear decision and next best action. No guessing, no manual lookups, no blind routing.
Integration Standard
100% CLIENT-SIDE FREE
Integration happens entirely in the cloud, requiring zero IT resources.
REAL-TIME PAYER MAPPINGS
Synchronizes commercial group rules every night automatically.
CLINICIAN OWNERSHIP SESSIONS
Routes admin work to clerks, instantly inside existing workflows.
Seven Pillars of Claim Integrity
Clinical Appropriateness
Evaluates diagnosis codes against label and off-label necessity guidelines.
Formulary Coverage
Checks specific plan tiering, exclusions, and preferred alternatives.
Benefit Channel
Determines whether the drug falls under medical or pharmacy benefit.
Utilization Management
Identifies step therapy, quantity limits, and age/gender restrictions.
Claim Readiness
Ensures all required fields (NPI, DEA, DAW) are present and valid.
Drug Intelligence
Checks for interactions, duplicate therapies, and REMS requirements.
Next Best Action
Provides specific, actionable steps to resolve any identified issues.
Seven Executable Outcomes
Every prescription routed to one of seven outcomes. No dead ends. No lost information. Every claim exits the engine with an answer and a single next best action.
Submit
Ready for clean claim submission.
Prior Auth
Returns PA policy details with pre-filled documentation and clinical justification.
Medical Benefit
Routes to medical billing channel.
Request Data
Missing documentation flagged with specific gaps.
Clinical Review
Routed to pharmacist or prescriber for clinical decision.
Manual Review
Held for human reviewer with full context.
Escalate
Immediate route to compliance or leadership.
Levothyroxine 50mg
Dispense as written (DAW 1)
Levothyroxine 50mg
Generic substitution applied
From blocked to payable in one click.
BRIVIACT, brand-name antiepileptic, written for a patient on Humana.
RxAI flags it. Humana formulary excludes BRIVIACT in this plan year. Step therapy requires documented failure of two generic alternatives.
RxAI surfaces levetiracetam as the covered generic. The substitution is routed to the prescriber with the formulary citation and the clinical equivalence note already populated.
The prescriber approves. The new claim is submitted, validated, and paid.
The rejection never happens. The patient never leaves empty-handed.
Built for the operators who carry the rejection cost.
Physician groups and specialty practices
Stop chasing prior auths and focus on patient care.
MSOs and health systems
Standardize prescribing workflows across all locations.
Pharma distributors
Ensure smooth delivery and payment for high-cost drugs.
Specialty pharmacies
Eliminate intake bottlenecks and dispense faster.
Sits between your prescribing layer and your claims infrastructure.
RxAI ingests prescriptions from EHRs, pharmacy systems, or paper portals, applies the decisioning logic, formats the claim, and hands it off to the billing system. It's the workflow you already run.
No rip and replace. No new screens to learn. The decision shows up where the work already happens.
Integrations
Implementation
A correctly written prescription and a payable claim are not the same thing.
Most pharmacy rework is caused upstream by billing logic trying to fix formulary mismatches. RxAI stops the wrong inputs from ever reaching the billing team.
Each one looks like a billing problem on the way out. None of them started there.
See RxAI in your Environment
RxAI helps specialty care teams navigate payer restrictions, prescription complexity, and therapy decisions with intelligent clinical and revenue insights before delays impact care.