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MAINS LAB

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Fraud, Waste & Abuse

Health

Motor

Overtreatment detection

Car damage calculation

Automated underwriting

PBM engine

Med. Service Pre-approval

By product

Health

Motor

By industry

Pharmacy Benefit Management engine

HOW IT WORKS

FREE TRIAL

Innovative solution for insurance companies and TPAs to fight excessive claims and admin expenses

accuracy of medical decisions

99

automation level
of pharmacy pre-auth
and claims

90

Wrong prescriptions can harm the patient

Strict regulations on pharmacy approvals time

Regulatory & Clinical Guidelines compliance

Reduce excessive claims
& administrative expenses

Clinically safe and patient-clear decisions

Automated drug checks & Cost savings

Problem

Solution

excessive prescriptions

20

Regulation compliance

Works with FDA / SFDA drug codes (and NPHIES denial codes in KSA). Compatible with EBP technical requirements

AI-powered

Solution can work with free text description of drugs. Important for the providers whose price lists are not codified

Large Medical Database

Covers 10K ingredients & 50K brand names, 50M interactions between ingredients and 25M drug-diagnosis combinations

References to Clinical Guidelines

All PBM’s decisions coming with understandable description and contains reference to UAE MOHAP /KSA / US / EU clinical sources or FDA / SFDA

Flexible customization

Ability to tune medical (drug-diagnosis, drug-drug, etc.) and technical (drug-members class) criteria

System features

Pharmacy claim

When a pharmacy submits a claim, MainsLab PBM checks if it matches the prior approval. If no approval is needed, medical checks are performed to determine if the claim should be paid

Prior approval for drugs is a recommen-ded practice, however, if it’s absent, regular medical checks for dosage, course size etc will be applied by PBM

Pharmacy dispensation

Patient with his approved prescription now goes to the pharmacy. PBM checks that the drug dispensed is the drug that was prescribed

Now the medical checks are not needed, and the pharmacy will get compensation if they fulfil the prescription correctly

Prescription Approval

Patient goes to the hospital for a prescription. Medical checks of the prescribed drug are done by MainsLab PBM

The approved prescription includes drug's scientific name, dosage, quantity and duration. The patient can now go to the pharmacy or receive the medication at the clinic

Timeframes for full implementation of PBM in your company

PBM Process

3 weeks

to start using the solution

4 weeks

to receive and analyze the first results

OPEN

List of modules and the sources

Technical & Regulatory

High dosage warnings (dosage is excessive/dangerous for the patient)

Source KSA: SFDA drug instructions base
Source UAE: FDA drug instructions base

Drug Coverage: Exclusions of drugs / conditions based on members TOB

Source: Payer's TOB

Tiering (classification of brand/generic with check of co-payments)

Source: Business logic / Payer's TOB

Devices/consumables/milk checks based on Payers ToB

Source: Business logic / Payer's TOB

Utilization rules: one-time quantity / annual limits / monthly limits

Source: Business logic / Payer's TOB

Authorized vs dispensed medication (for products requiring pre-auth)

Source: Business logic

SFDA formulary check

Source KSA: SFDA drug instructions base
Source UAE: Local governmental lists of approved medications (e.g., mohap.gov.ae/en/w/registered-medications-list)

Medical

Drug-to-Age check

Source KSA: SFDA drug instructions base
Source UAE: FDA drug instructions base, https://dps.fda.gov/medguide

Diagnosis-to-Gender and drug-to-gender check

Source: Medical logic

Drug-to-Drug interaction
(including form of drug)

Source KSA: SFDA drug instructions, https://drugcentral.org,
https://www.drugs.com/
Source UAE: FDA drug instructions, https://dps.fda.gov/medguide,
https://www.drugs.com

Drug-to-Diagnosis contraindication

Source KSA: SFDA drug instructions, https://drugcentral.org,
https://www.drugs.com/
Source UAE: FDA drug instructions, https://dps.fda.gov/medguide, https://www.drugs.com

Course size limit

Source: Medical logic

Drug vs Clinical guidelines
(medical necessity)

Source KSA: KSA clinical guidelines (CHI, saudifamilymedecine, etc.), worldwide clinical guidelines, medical logic
Source UAE: UAE clinical guidelines (mohap.gov.ae,
doh.gov.ae/en/ resources/guidelines), worldwide clinical guidelines (UpToDate, MedScape), medical logic

Therapeutic duplication
(based on ATC drug classification)

Source: ATC drug classification
(https://www.who.int/tools/atcddd- toolkit/atc-classification)