Rebate invoice validation, every claim checked against the contract and every dispute backed by its clause
Every rebate invoice line checked against the contract, and every dispute backed by its clause.
See one case, screen by screen ↓Every quarter each payer sends an invoice and a utilization file — hundreds of thousands of claims, often in its own layout, with adjustment files and prior-quarter re-bills on top. The contract that decides what is owed sits in a PDF and three amendments: the base rate, the exclusivity rebate and the months it applies, the 340B and managed Medicaid exclusions, the opted-out groups in a schedule, the look-back, the fee cap. And the payment clock runs from the day a complete invoice arrives.
So most of the time goes on tying files to the invoice total and looking up terms, and the checks that find money — formulary position month by month, 340B contract pharmacies on the dispensing date, claims already paid in an adjustment file — get sampled or skipped. Disputes go out without the clause and the rows, payers question them, and the ones that would have held are paid anyway to make the due date.
Estimated split for one payer invoice, by hand and with the solution, adding up to the 19-day and 4.2-day medians above.
Seven specialist agents read the invoice and contract, check every claim and build the dispute and payment; the rebate lead decides.
It is October 7 in the Q2 2026 rebate cycle: ten payer invoices, $158.7M invoiced. Here is the rebate lead’s day, screen by screen, in the working solution.
Priya opens the quarter board: $158.7M invoiced across 1.30M claims and 10 payers, 1,245,920 claims already checked and $8.26M found disputable. Needs you lists what waits for her — the Bluepeak Medicare Rx payment packet to sign, due Oct 9, and 6 Crestline Rx exceptions worth $2.62M, due Oct 16. The payment runway puts every invoice on its due date, by channel.
Agents today, 07:12: “Invoice & file intake read the Harbor Union Rx invoice and 2 files · 36,940 claims tie to the total.”
Harbor Union Rx sent its Q2 invoice this morning: $4,284,100 on 36,940 claims under contract HUR-2025-022, Amendment 1. One click on “Check this invoice” and the intake agent maps the layout and ties the claims to the total, the term reader pulls the terms in force, and three checkers run in parallel. 36,362 claims pass all 10 checks; 3 exceptions worth $162,100 wait for a decision, the first one 388 claims filled by 340B contract pharmacies, with § 6.3 highlighted beside it.
“Recommended: dispute in full — $96,400.”
Crestline Rx billed $48,620,400 on 412,880 claims in three files; the agents checked it in 11 minutes and found 8 exceptions. The largest: Crestline billed the 6% exclusivity rebate on every Veltrimab claim in June. Under § 4.2(b) it is payable only for months in which Veltrimab is the sole preferred brand for the whole month — and a competing brand moved to Tier 2 preferred on June 12.
“5,440 June Veltrimab claims × $262.80 (6% of $4,380 WAC) = $1,429,632” · 97% sure
The Payer data tab opens Crestline’s June formulary file, CRX_FORMULARY_2026-06.txt, received Jul 9. The line that settles it is highlighted: from 06/12/2026, Ostravel, the competing IL-23 inhibitor, sits on Tier 2, Preferred, with no restriction. Four sample claims behind the exception sit underneath, each with its pharmacy, plan and the 34% rate billed.
“Payer data is used only to validate this invoice, under the data agreement with Crestline Rx. Every read is in the audit trail.”
2,318 claims, $638,940, were filled by pharmacies acting as contract pharmacies for 340B covered entities on the day of dispensing. The HRSA database extract, refreshed at 06:00, names each pharmacy and its covered entity; 1,904 of the claims also carry Submission Clarification Code 20, and 414 were matched by pharmacy and date. § 6.3 excludes them because the 340B discount was already given.
214 Veltrimab claims are for 2 or 3 cartons in 28 days. The label dosing table allows 2 cartons in the first 28 days as a loading dose, then 1 every 28 days. 131 of the claims are first fills and look valid; 83 are refills above label dosing. The checker recommends paying the 131 first fills and disputing the 83 refills, $37,310, at 78% confidence.
“131 first fills for the patient — those are loading doses and look valid. 83 are refills above label dosing. A person should decide.”
Sam Patel already disputed the duplicates paid in the Q1 adjustment file and the Puerto Rico claims on Oct 6. Priya reviews the agents’ recommendations for the six still open — five disputes in full and the partial on quantities, $2,560,332 in all — and applies them. The invoice now stands at $2,994,852 disputed and $45,625,548 to pay.
“You stay the decider — each will show your name.”
The letter writer turns the decisions into one letter to Crestline’s manufacturer rebate services, sent through the Crestline rebate portal. It states that all 412,880 claims were validated, disputes the claims under § 8.2 and commits to pay the undisputed $45,625,548 by Oct 16. Items A to H each carry the clause, the claim count, the amount and an attached claim list. Priya sends it.
Only decided items go into a letter, and a person sends it.
The packet holds the invoice and utilization files, the results of all 10 checks, the 8 decisions with names and times, the letter, the clauses cited and the calculation from invoiced to paid. Priya chooses the meaning, “I prepared and approve this payment”, and signs with her name and password. Her signature, its meaning and the time are kept with the packet.
Because the payment is above $25M, Omar signs as controller, on his phone. The Best Price check finds the Veltrimab rebate net of disputes at 30.6% of WAC, below the 36% review threshold, so there is no new Best Price and Lena Ortiz in government pricing is informed. The payment is scheduled in the ERP for Oct 15, a day before it is due, and the accrual true-up of −$806,452 is posted to GTN accounting.
No payment without the required signatures; a payment that could set a new Best Price waits for government pricing.
The same Crestline invoice, seen by the five people who carry it — what their quarter looked like, and what it looks like now.
Seven specialist agents read the invoice and contract, check every claim and build the dispute and payment; the rebate lead decides.
Reads payer invoices and utilization files in any layout, maps them to the rebate standard, merges main and adjustment files and ties the claims to the invoice total.
Reads each rebate agreement and every amendment and keeps the terms in force — rates, tier conditions, exclusions, fees, look-back, schedules — each linked to its clause.
Checks products, dates, plans, groups, territories and look-back, and the formulary position month by month against the tier conditions in the contract.
Finds claims billed twice across files and four prior quarters, 340B contract-pharmacy claims and claims also on a State Medicaid rebate invoice.
Recalculates the rebate for every claim with the rate grid and WAC history, checks administrative fees and price protection, and compares quantities with label dosing.
Turns the rebate lead’s decisions into one dispute letter that states the undisputed amount and payment date, and cites the clause and attaches the claim list for each item.
Builds the payment packet, routes it for e-signature by amount, runs the Best Price check, schedules the payment in the ERP before the due date and posts the accrual true-up.
Decides each exception. The agents propose; a named person decides.
The rebate team can ask about any invoice, exception or contract term — or tell it what to change. Answers come from the payer files, the contract terms and every decision on record.
Why is Crestline’s June exclusivity rebate disputed?
Crestline billed the 6% exclusivity rebate on all 5,440 June Veltrimab claims. The contract pays it only for months when Veltrimab is the sole preferred brand for the whole month, and the June formulary file moves a competing brand, Ostravel, to Tier 2 preferred on Jun 12. So June is not an exclusive month. Disputed: $1,429,632.
Which invoices are due in the next 10 days?
Two invoices, $76.5M in total: Bluepeak, due Oct 9, in approval, and Crestline, due Oct 16, in your review. Bluepeak is first — only your signature is missing.
Does the Crestline payment set a new Best Price?
Crestline’s Veltrimab rate after disputes is 30.6% of WAC — below the 36% review threshold, so it does not need government pricing review and does not set a new Best Price. Part D and managed Medicaid rebates are excluded from Best Price, so for those invoices the check only records the payment for government pricing.
Flag any invoice where a competing brand joined the tier mid-quarter
Done. New check: hold invoices where a competing brand joined the tier mid-quarter. It compares every monthly formulary file with the tier conditions in each contract. Across the 8 checked invoices it finds Crestline — already an exception — and nothing new elsewhere. The check is on in Settings and in the audit trail.
13 screens from the working solution, on its sample data. Pick one to see it large.
The checks, thresholds and signers are settings, so each manufacturer’s approval matrix runs as it is.
| Setting | Default | Choose from |
|---|---|---|
| Checks on every invoice line | 10 on | Each check switched on or off — product and dates, plan and group, formulary month by month, rates and fees, duplicates, 340B, Medicaid overlap, quantity, look-back, territories |
| Controller signs payments above | $25M | In steps of $5M, from $5M |
| Government pricing review when the rebate is above | 36% of WAC, after disputes | In steps of 1%, from 20% |
| Ask me to decide every exception above | $1,000 | In steps of $500, from $0; smaller ones follow the recommendation and are listed in the letter |
| Dispute letters are signed by | Priya Raman | Priya Raman · Sam Patel |
| Each person’s role | Priya Raman · Decides and signs | Decides and signs · Decides under $250K · Owns contract terms · Second signature · Best Price review, or Viewer |
| Duplicate look-back | 4 quarters back | Rx number + fill date + pharmacy, across main, adjustment and prior-quarter files |
| Your own checks | Add in plain words | e.g. hold invoices where a competing brand joined the tier mid-quarter |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample rebate data · “target” = the design goal, measured in the live solution · “estimated” = our estimate. People, payers, products and contracts named on this page are characters in the working solution.
Checking each claim on a payer’s rebate invoice against the contract before paying it: is the product on the contract, the plan and group eligible, the formulary position held for the month, the claim not already paid or covered by a 340B or Medicaid discount, the rate and fee right. The Rebate Claim Validation Agent runs those checks on every claim, not a sample, and groups what fails by cause.
Commercial, Medicare Part D, managed Medicaid and employer coalition invoices. Each is checked against its own contract — for example, the Part D contract’s eligible plan benefit packages, or the managed Medicaid agreement’s overlap with State Medicaid rebate invoices.
The duplicate and overlap finder checks every dispensing pharmacy against the HRSA 340B database on the dispensing date and reads Submission Clarification Code 20. Claims from contract pharmacies of covered entities are grouped into one exception with the clause that excludes them.
Yes. The eligibility and formulary checker reads the payer’s monthly formulary file and decides whether the tier, parity, prior authorisation and exclusivity conditions in the contract held for the whole month — which is how it finds an exclusivity rebate billed for a month a competing brand joined the tier.
No. The agents recommend; only a person disputes or accepts an exception, and only a person sends the dispute letter. Payments need the rebate lead’s e-signature, the controller’s above the threshold, and a Best Price check before release.
The undisputed amount and the date it will be paid under the disputes clause, then one lettered item per decision with the plain reason, the clause, the claim count, the amount and an attached claim list. Accepted items are left out.
Yes. The contract term reader reads each agreement and its amendments in date order and keeps the terms in force, each linked to its clause. New or changed terms are used only after contract operations confirms them.
The Agentic Solution Engine builds and deploys it from your requirements — your rebate contracts and amendments, your approval matrix and a past quarter of payer invoices and files — and it goes live once every quality gate has passed. We will walk you through it on your own invoices first.
A global value dossier drafted section by section, with every sentence linked to its source and checked against the label.
1-min filmPayer ContractsEvery payer contract and amendment becomes cited terms in force, with every deadline on a clock.
1-min filmCoverage MonitorEvery payer policy change caught within a day of posting, and checked against what the plan contracted.
1-min filmWe’ll run Rebate Validation on a past quarter of your own payer invoices and contracts.