Standard Operating Procedure
OPS-SOP-002 — PBM Invoice Processing (ProAct)
1. Purpose
This SOP defines the procedure for receiving, validating, approving, and remitting payment for Pharmacy Benefit Manager (PBM) invoices from ProAct under each participating employer plan under the Unity Care Member Plan Master Trust. It ensures Rx funding is accurate, contract-compliant, and properly documented.
2. Scope
Applies to all PBM invoice cycles from ProAct. Covers invoice receipt through GL reconciliation. Excludes medical claims (see OPS-SOP-001) and monthly premium (see OPS-SOP-003).
3. Roles & Responsibilities
| Role | Responsibility |
|---|
| Operations | Primary owner. Log receipt, validate invoice against contract, coordinate QC, prepare payment packet. |
| Compliance | Run QA/QC attestation (SUB-003), verify controls met before payment. |
| Finance | Sign off on payment packet. Schedule remittance. GL posting and reconciliation. |
| ProAct (PBM) | Submit invoice. Issue corrections on request. |
4. Procedure
Subprocess reference: SUB-005 (master flow), SUB-003 (Compliance QA/QC)
1. Receive Invoice: ProAct sends Rx invoice per contract schedule. Operations logs receipt with date/time in the Invoice Log [TBD]. If invoice is not received by [TBD], Operations contacts ProAct.
2. Validate Invoice vs. Contract: Operations validates the invoice against the PBM contract terms and rate schedule:
- Correct billing period
- Rates match contracted schedule
- Administrative fees within agreement
- No duplicate line items
- Total matches sum of line items
3. Discrepancy Handling: If discrepancies are found, Operations requests written correction from ProAct and logs a dispute case per OPS-SOP-004. Process returns to Step 2 upon receipt of corrected invoice.
4. Compliance QA/QC (SUB-003): Compliance runs the QA/QC attestation subprocess. Verifies validation complete, controls met, redaction verified (no PHI in packet), approvals present, and retention locations recorded. If controls fail, packet returns to Operations.
5. Prepare Payment Packet: Operations prepares the payment packet using the contract approval form. Packet signed by Finance and Compliance. Contains: invoice summary, validation confirmation, compliance attestation — no PHI.
6. Finance Schedules Remittance: Finance schedules remittance per PBM contract payment terms. Payment method: [TBD per contract]. Finance confirms scheduled payment date with Operations.
7. Bank Confirmation: Operations captures and timestamps bank confirmation of payment. Stored in evidence retention location [TBD].
8. GL Posting & Reconciliation: Finance posts payment to GL within [TBD] business days. Discrepancies trigger dispute per OPS-SOP-004.
5. Controls
| Control | Description | Owner | Frequency |
|---|
| Contract Validation | Invoice rates and fees verified against PBM contract | Operations | Every invoice |
| Duplicate Check | Invoice line items checked for duplicates | Operations | Every invoice |
| Dual Sign-Off | Finance and Compliance sign payment packet | Finance, Compliance | Every invoice |
| Compliance Attestation | SUB-003 attestation issued before payment scheduled | Compliance | Every invoice |
| Bank Confirmation Capture | Payment confirmation timestamped and retained | Operations | Every invoice |
| GL Reconciliation | Payment posted and reconciled within [TBD] days | Finance | Every invoice |
6. Evidence Retention
| Document | Location | Retention Period |
|---|
| ProAct invoice (original) | PHI-aware secure location [TBD] | 6 years (ERISA) |
| Validation checklist | Ops records [TBD] | 6 years (ERISA) |
| Dispute log (if applicable) | Dispute log [TBD] | 6 years (ERISA) |
| Compliance attestation | Compliance records [TBD] | 6 years (ERISA) |
| Signed payment packet | Finance records [TBD] | 6 years (ERISA) |
| Bank confirmation | Finance records [TBD] | 6 years (ERISA) |
| GL reconciliation record | Finance records [TBD] | 6 years (ERISA) |
7. Escalation
| Trigger | Action | Escalation Owner |
|---|
| Invoice not received by [TBD] | Contact ProAct; escalate to Finance if unresolved by [TBD] | Operations |
| Contract rate discrepancy | Log dispute; request correction; escalate to Legal if unresolved | Operations |
| Compliance QA/QC fails | Return to Operations; do not schedule payment | Compliance |
| Payment rejected or reversed | Notify Finance and ProAct immediately; log and investigate | Finance |
⚠️ Open Items — Tracking Tools To Be Built
- Invoice Receipt Log: Timestamped log of PBM invoice receipt and processing steps [TBD format]
- PBM Contract Rate Schedule: Reference document for contract validation checks [TBD format]
- Invoice Validation Checklist: Standardized checklist template for Step 2 [TBD format]
- Dispute Log: Case tracking for discrepancies — shared with OPS-SOP-004 [TBD format]
- Payment Packet Template (Contract Approval Form): Standardized form signed by Finance and Compliance [TBD]
- Evidence Retention Index: Master index of retained documents per invoice cycle [TBD format]
OPS-SOP-002 | Unity Care Solutions, LLC — Internal / Confidential
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