PBM Platform - Nirvana Health

Aria PBM

PBM Modules

Click the buttons below to jump to specific PBM modules.

Membership Gateway

Aria Membership Gateway extracts and consolidates information across all departments of the PBM, providing plan sponsors with a 360° patient view that enhances critical health/financial decision-making and results in best outcomes.

Aria empowers customer services representatives (CSRs) by providing comprehensive information in a single interface.

When a prescriber requests services from a CSR, comprehensive information including eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, adherence, proactive FWA index, and MTM are accessible.
When a pharmacist requests services from a CSR, comprehensive information including eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, adherence, proactive FWA index, MTM, claims, and financial reconciliation are accessible.
When a patient requests services from a CSR, comprehensive information including eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, cost saving opportunities, adherence, and MTM are accessible.

Aria empowers plan sponsor staff:

By pushing comprehensive patient information into customer service, case and care management, and utilization management workflows, to facilitate effective member engagement and optimal health/cost outcomes.
By providing unprecedented operational visibility to conduct PBM oversight functions, such as monitoring contractual obligations and service level agreements (SLAs), with full insight into compliance and regulatory requirements and performance
By integrating a comprehensive view of the utilization of drug benefits by prescribers, pharmacists, and members
By allowing plan sponsors to effectively manage overall administrative/medical risk

Formulary Management

Formulary Management System

Formulary management requires the coordination of many moving parts in order to meet the unique needs of plan sponsors. At the core of Aria Formulary Management is the capability for users to perform extensive modeling and analytics to land upon the most cost-effective and quality-optimized standard and specialty formularies.

Aria Formulary Management provides:

A highly customizable and intuitive user interface
AI-driven formulary design and management of a variety of formularies for Commercial, Medicare Part D, Medicaid, and Exchange lines of business
Dynamic computational modeling capabilities weigh all clinical and relevant financial variables to derive an ideal formulary with optimal financial (lowest net cost) and clinical outcomes.
The ability to recommend selective pharmacogenomics analysis based on variability of drug therapy.
System-generated gap analysis highlighting differences between optimal and existing formularies.
The ability to “accept/deny” system-recommended formulary changes and to generate a corresponding multi-year transition action plan.
Member and prescriber engagement tools based on habitual member and prescriber utilization patterns.
Support for multiple third-party drug databases, classification systems, and drug attributes to build and manage a formulary.
Configuration of drug lists, drug tiers, and utilization management rules (PA – Prior Authorization, ST – Step Therapy, and QL – Quantity Limits) for single or multiple formularies.
Comprehensive and streamlined formulary change management process for efficient decision making and effective implementation, supported by the fully integrated Aria platform.
Powerful analytics to analyze drug utilization trends, Utilization Management (UM) edits, and plan-to-plan comparisons.
Built-in CMS rules, guidelines, and RXCUI (RxNorm Concept Unique Identifer) crosswalk to seamlessly generate formulary and UM files.
Customization and dynamic generation of forms including Prior Authorization forms, member and provider notices, and drug lists.
Promotion of formulary compliance using extensive edits and alerts at point of care and point of sale by leveraging a seamless integration with clearinghouses and member engagement through our integrated apps.

Utilization Management

UM System

Aria Utilization Management offers a fully configurable solution to yield the optimal balance of clinical efficacy and cost management strategies.

Key configurable Utilization Management rules include:

Prior Authorization
Step Therapy
Quantity Limits
Drug Utilization Review
Overutilization Thresholds
Duplicate Therapies
Drug-Drug Interactions
Drug-Disease Interactions

Ease of use and configuration allow business users to quickly and effectively implement, test, and productionize changes.

Claims Adjudication

Claims Adjudication System

In the marketplace, a pharmacy claims processing is often considered a commoditized and low value-added process. Dated PBM claims engines have fragmented and inflexible subsystems with incompatible data models — and they need to be replaced. Aria Claims Adjudication provides payers with a core transactional process that has is high-value and low-cost.

Aria Claims Adjudication provides users with:

Highly flexible, scalable, and automated adjudication of specialty and non-specialty claims.
Seamless integration of all Aria modules, including benefit design, formulary management, utilization management, network & pricing, and more.
A single system of recordfor eligibility, membership, prescribers, pharmacy network contracts, pricing, benefits, formularies, authorizations, and compliance rules. This enables seamless claims adjudication.
Rapid implementation timelines due to user configurability
The ability to impact prescribing at the point-of-care through delivery of actionable intelligence within prescribers’ workflows.
The ability to impact dispensing at the point of sale through delivery of actionable intelligence within pharmacists’ workflows.
The ability to impact member behavior through delivery of actionable intelligence within members’ mobile apps.
The ability to collaborate with plan sponsor staff through delivery of actionable intelligence within clinical workflows. This insight identifies opportunities to reduce pharmacy costs, reduce avoidable drug-impacted medical costs, and improve health outcomes.

Network & Pricing Administration

Network & Pricing Administration System

Aria Network & Pricing is a granular, multi-level configurable, and fully integrated module within the Aria platform. Aria Network & Pricing delivers cost management, quality improvement, oversight, and incentive alignment features. This module also facilitates prospective cost and quality modeling for better financial/clinical outcomes.

Aria Network & Pricing provides users with:

Streamlined system-driven pharmacy network contracting and credentialing tools.
The ability to create quality-based, MTM, and mosaic sub-networks networks to optimize quality and cost outcomes.
The promotion of preferred contracting using quality and cost indices.
Intelligence and guidance to maximize the impact of desktop/onsite audits.
Real-time FWA alerts.
Geo-Access coverage analysis.
Real-time dashboards and modeling of actual paid amounts vs. plan sponsor contract guaranteed amounts.
The ability to leverage messaging space on standard NCPDP D.O transactions to communicate actionable information to pharmacies.

PDE & Encounter Management

PDE & Encounter Management System

Aria PDE & Encounter Management generates PDEs automatically and submits them to CMS. During PDE file generation, Aria performs built-in validation to ensure 99.9999% accuracy on the submitted PDE files. Aria PDE & Encounter Management also provides validation to ensure certain error codes will never be a result on the PDE return file. Examples of such error codes include: 633 GDCB is missing or invalid, must be >= zero, 654 The Brand/Generic Code is missing or invalid. Valid values are ‘B’ for brand or ‘G’ for generic, 703 The DOS cannot be less than the DOB and 704 The DOS cannot be greater than the date of death (DOD) + 32 days.

Aria PDE & Encounter Management provides tools and features to business users to allow adjustment, correction, and auditing of PDE submissions during the process of reconciliation. All errors related to claims processing are actively identified to allow resolution of any eligibility-related errors. All PDE submission and errors are available in real-time to the client through Aria.

Within the Aria platform, claim adjudication is fed by the eligibility engine, which keeps track of the eligibility of members on a “period of eligibility” basis. This includes but is not limited to LIS and SPAP. When updates to enrollment occur, the eligibility gateway engine analyzes the new eligibility updates along with the eligibility on file. In this process, the system identifies any encounters/ PDEs which might have occurred during the eligibility change period and flags any claims that are in question. The system alerts are set up to notify if claim restacking / adjustments are required due to FIR, reversals, or PDE deletions.

CMS currently requires the following for PDE submissions, all of which are available through Aria PDE & Encounter Management:

Original PDEs are submitted within 30 days following Date of Service or Date Claim Received, whichever is greater.
Adjustments and deletions resubmitted within 45 days following date of discovery.
Rejected records resubmitted within 45 days following receipt of rejected status from CMS.
Plans must submit at least one successful PDE file per month.

The frequency of PDE submissions can also be configured within Aria.

Rebate Management

Rebate Management System

Aria Rebate Management is an integrated, comprehensive, and flexible rebate management platform that enables contract setup and maintenance with minimal personnel support.

Aria Rebate Management provides:

A seamless, information-rich, configurable, and predictable rebate optimization tool for all plan sponsors.
AI modelling of optimal formulary and benefit designs through extensive analysis of all products/plans and their respective utilization, P&T committee therapeutic recommendations, plan-paid amount, and member-paid amount.
Instantaneous/easy-to-model formulary changes, which effectively support the P&T committee process with potential rebate impacts of proposed changes.
Full and transparent access to all rebate results for all stakeholders, and real-time performance of rebate contracts based on preset thresholds to determine planned to actual results.

Designed with payer staff needs in mind, Aria Rebate Management provides users with the following sub-modules:

Rebate contract management
Rebate setup/configuration
Rebate modeling, data analytics, and forecasting
Automatic rebate invoicing generation
Dynamic rebate reporting
Streamlined reconciliation

Medication Therapy Management

Medication Therapy Management System

The goal of Aria MTM is to empower plan sponsor staff, pharmacists, and prescribers with the needed tools to work collaboratively to produce low cost and high-quality MTM outcomes.

Aria MTM delivers a fully integrated MTM solution that provides the following:

Fully configurable with automated patient identification, enrollment, and real-time notification to the prescriber at the point-of-care.
Every time a prescriber prescribes a new medication, Aria MTM dynamically analyzes a range of factors, including cost, prescriptions, diseases, additionally configured criteria, and newly prescribed medication to determine the MTM eligibility of the patient. If the patient is MTM eligible, the prescriber is notified at the point-of-care to complete the comprehensive medication review (CMR).
The CMR is pre-populated with prescription history, which streamlines the workflow for the prescriber, enabling easy entry of OTC and non-PBM recorded medications.
All available pharmacy, medical, and lab data are integrated to provide the following alerts:
- Generic substitution
- Therapeutic appropriateness
- Inappropriate duration of drug treatment
- Medication adherence
- Clinical abuse and misuse
- Drug-disease interactions
- High or low dosages
- Drug-drug interactions
- Over and under utilization
- CMR
- Drug-gender precautions
- Drug allergies
- Drug-pregnancy precautions
- Drug-age precautions
A new Patient Medication Listing (PML) and a Medication Action Plan (MAP) is automatically generated for patient consultation.
After successful CMR, a compensation payment is queued up automatically. This CMR process is completed in less than 15 minutes.

Integrated Data Cloud Platform

Integrated Data Universe

Aria Data Warehouse has been built to meet all user reporting and analytical requirements and is constantly evolving to best meet the needs of users. Aria Data Warehouse can be replicated in real-time or in batch mode from Aria Claims Adjudication and can also be integrated with the client’s downstream systems or data warehouse for any further analytics. We have created specific report models for ad-hoc reporting, which power users can access and run various ad-hoc reports through our data warehouse.

Data inputs include:

Eligibility data
Pharmacy claims data
Other claims data (medical, DME, labs, dental)
MTM data
Medication adherence data
Historical PBM data
Rebate management data
Network and pricing data
Health plan provider data
Formulary and benefit data

Pharmacy Care Management

Pharmacy Care Management System

nirvanaHealth has unique abilities to support and empower risk-bearing entities through our Aria Pharmacy Care Management capabilities. Aria is uniquely able to integrate medical, pharmacy, and lab data, providing nirvanaHealth the ability to engage physicians meaningfully at the point-of-care by providing actionable intelligence that will lower costs and improve patient outcomes. nirvanaHealth proactively engages physicians at the point-of-care, as well as pharmacists at the point-of-sale, alerting them within their EMR and practice management systems–therein avoiding disruption to their workflows.

Alerts include the following: Generic substitutions, Inappropriate duration of drug treatment, Drug allergies, Clinical abuse and misuse, Inappropriate dosages, Cost savings opportunities, Coverage gap prediction and prescription planning, Drug-Disease Interactions, Over and Under Utilization, Drug-Age Precautions, Drug-Gender Precautions, Therapeutic Appropriateness, Medication Adherence, Star Ratings, Specialty Management, etc.  

Additionally, nirvanaHealth provides extensive capabilities to leverage our Aria platform to create and administer disease-focused clinical programs.

Accountable Care System

Chronic Care Management System

Forty-five to fifty percent of the overall US population has at least one chronic condition, and one in four Americans have multiple chronic conditions. This population utilizes approximately 86% of the total US healthcare spend. While pharmacotherapeutic research has produced many novel therapies to reduce the disease burden of chronic conditions, many patients are still unable to control their illness due to prescription and care plan non-adherence.

We believe that engaging and motivating this population to take charge of their health early in their diagnosis will reduce avoidable medical costs significantly. Technology lies at the heart of our solution. Smart-phones, machine learning, and connected devices are reshaping the way people interact with the world, and these same technologies should reshape healthcare. Aria delivers targeted actionable intelligence at all nodes of the care continuum, while continuing to support, educate, and engage patients as a companion in their health journey. Click the Learn More button to discover how the Aria platform drives our Accountable Care Management services.

Mobile Apps & Portals

nirvanaHealth Member Platforms

nirvanaHealth provides members, plan sponsors, pharmacies, and prescribers with the industry’s first cloud-based PBM platform, Aria. Aria Mobile Apps & Portals provides unparalleled access and transparency opportunities for stakeholders collaboratively manage pharmacy benefits.

Aria Apps & Portals provides user-centric web-based tools catered to the specific needs of:

Members
Plan Sponsors
Pharmacies
Prescribers

Aria integrates all data, creates a 360-degree member view, derives actionable intelligence, and pushes that actionable intelligence to all care continuum stakeholders within their workflows.

All relevant information is maintained at the same source, ensuring a consistent, up-to-date, and holistic view of them member, including all patient profiles, conditions, treatments, benefit configurations, reports, pharmacy network information, and other data. Role-based authentication allows for full control of all user access permissions. By offering fully customizable access to rich a variety of information, nirvanaHealth is able to grant clients full and uncompromising transparency into all operational, clinical, and financial areas.

Mobile Apps

Portals