In the Purchase Validation module, account eligibility statuses indicate whether an account currently meets a manufacturer's requirements for maintaining access to 340B pricing offers under a manufacturer's policy.
How are eligibility statuses are determined?
Eligibility is determined by comparing validated purchases with claims submitted by the covered entity. Each manufacturer establishes its own acceptable threshold for the difference between validated purchases and submitted claims.
An account’s eligibility status is based on the relationship between validated purchases and submitted claims and may be classified as Eligible, At Risk, or Suspended.
Eligible
An account with an Eligible status currently meets the applicable manufacturer's claims submission and eligibility requirements and maintains access to the manufacturer's 340B pricing offer.
Eligibility is determined by the manufacturer's policy. For some manufacturers, a contract pharmacy's eligibility may depend on the status of associated CE Pharmacies and Clinics, in addition to its own claims submission activity.
What this means:
Access to the manufacturer's 340B pricing offer is maintained.
Applicable claims submission and purchase validation requirements are currently satisfied.
Any associated account dependencies required by the manufacturer's policy are satisfied.
No immediate remediation action is required, but covered entities should continue submitting claims regularly to maintain eligibility.
Note: An Eligible status does not necessarily mean that eligibility is determined solely by the account's own claims. Some manufacturer policies also consider the status of associated CE Pharmacies and Clinics.
At Risk
An account with an At Risk status is approaching the manufacturer's threshold for suspension. Access to the manufacturer's 340B pricing offer remains available, but corrective action may be required to prevent suspension.
At Risk status is determined by the manufacturer's policy. An account may become At Risk when unvalidated purchases outpace supporting claims and approach the manufacturer's allowable imbalance threshold. For some manufacturers, a contract pharmacy may also become At Risk because an associated CE Pharmacies and Clinics account is At Risk, even if the contract pharmacy has satisfied its own claims submission requirements.
What this means:
Access to the manufacturer's 340B pricing offer is still maintained.
The account is approaching the manufacturer's suspension threshold or is affected by an associated account's status.
Additional claims may need to be submitted for the affected account or associated CE Pharmacies and Clinics to maintain eligibility.
Note: A contract pharmacy's At Risk status does not always indicate missing claims at that pharmacy. Review the applicable manufacturer's policy and any associated CE Pharmacies and Clinics accounts to identify the underlying cause before taking corrective action.
Suspended
An account with a Suspended status no longer has access to the manufacturer's 340B pricing offer. Corrective action is required to restore eligibility.
Suspended status is determined by the manufacturer's policy. An account may become Suspended when unvalidated purchases exceed supporting claims beyond the manufacturer's allowable imbalance threshold. For some manufacturers, a contract pharmacy may also become Suspended because an associated CE Pharmacies and Clinics account is Suspended, even if the contract pharmacy has satisfied its own claims submission requirements.
What this means:
Access to the manufacturer's 340B pricing offer is suspended.
The account has exceeded the manufacturer's allowable imbalance threshold or is affected by an associated account's status.
Additional claims may need to be submitted for the affected account or associated CE Pharmacies and Clinics to restore eligibility.
Note: A contract pharmacy's Suspended status does not always indicate missing claims at that pharmacy. Review the applicable manufacturer's policy and any associated CE Pharmacies and Clinics accounts to identify the underlying cause and determine the corrective action needed to restore eligibility.
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