Pharmacy Billing and Prior Authorization

Pharmacy Billing and Prior Authorization

Introduction

HMIS integrates pharmacy dispensing and billing into a single workflow. Every dispense transaction — retail sale, ward issue, BHT inpatient supply, wholesale, or donation — generates a corresponding billing record in real time. Charges are linked to the patient encounter, payment method, and dispensed items for complete financial traceability. For credit patients and insured patients, HMIS supports a pre-settlement (prior authorization) workflow where billing is held for approval before the transaction is finalised.

Navigation

Function	Menu Path
Retail Sale Billing	Main Menu → Pharmacy → Dispensing → Retail Sale
Ward / BHT Billing	Main Menu → Pharmacy → Dispensing → Ward Issue
Wholesale Billing	Main Menu → Pharmacy → Dispensing → Wholesale
Pre-Settlement (Prior Auth)	Main Menu → Pharmacy → Billing → Pre-Settlement
Sale Returns / Refunds	Main Menu → Pharmacy → Returns → Sale Return
Pharmacy Bill Search	Main Menu → Pharmacy → Reports → Bill Search
Supplier Payment	Main Menu → Pharmacy → Procurement → Supplier Payment

Pharmacy Bill Types

BillType	Description
PharmacySale	Retail OPD dispensing — cash or card payment at counter
PharmacySaleWithoutStock	Credit dispensing — no stock decrement (for pre-billed or notional charges)
PharmacyWholeSale	Wholesale supply to external institutions or departments
PharmacyIssue	Department / ward issue (internal supply)
PharmacyBhtPre	BHT pre-billing — charges accumulate during inpatient stay, included in final bill
PharmacyGrnBill	Goods receive note — purchase from supplier
PharmacyGrnReturn	GRN return — credit from supplier
PharmacyPurchaseBill	Direct purchase (non-GRN)
PharmacyOrder	Purchase order
PharmacyAdjustment	Stock/price adjustment bill
PharmacyDonationBill	Donation receipt
PharmacyPhysicalCountBill	Stock take adjustment bill

Retail Sale Billing

On completing a dispense at the retail counter:

1. Drug items and quantities are selected (from prescription or manual entry).
2. Pricing is auto-populated from the AMP retail price or applicable discount scheme.
3. Payment method is selected (cash, card, credit company, patient deposit, voucher).
4. Bill is finalised — stock is decremented, billing record created, receipt printed.

PharmacyBill entity carries saleValue, purchaseValue, and freeValue (complimentary items) for margin reporting.

Inpatient BHT Billing

Pharmacy supplies to inpatients are pre-billed against the BHT (PharmacyBhtPre):

• Charges accumulate through the admission.
• At final bill preparation, all BHT pharmacy pre-bills are included automatically.
• Payment is collected as part of the single inpatient final bill — the patient does not pay separately at the pharmacy counter for each supply.

Credit Company (Insurance) Billing

For insured patients with a credit company scheme:

• Pharmacy bills can be routed to the credit company account.
• The co-payment portion is collected from the patient; the remainder is billed to the insurer.
• Outstanding credit pharmacy bills appear in the credit company receivables report.
• Settlement is processed through the credit company settlement workflow (see Credit Company Bill Settlement).

Prior Authorization (Pre-Settlement) Workflow

For high-cost medications or insured patients requiring pre-authorization before dispensing:

1. The pharmacist creates a pre-settlement record for the patient and proposed medication (PharmacyPreSettleController).
2. The pre-settlement is submitted for internal review or transmitted to the insurer.
3. The reviewer (pharmacy supervisor or insurer) approves or rejects the pre-settlement.
4. On approval, the dispense transaction is allowed to proceed and the bill is generated.
5. On rejection, the pharmacist is notified — alternative medication or patient-funded dispensing is considered.

The pre-settlement workflow ensures that high-cost drugs are not dispensed without coverage confirmation, reducing claim denials.

Discount Application

Pharmacy discounts are applied based on the patient's payment scheme, membership, or credit company agreement:

• Retail discount: percentage or flat discount on AMP retail price.
• Wholesale price: lower tier price for institutional or bulk supply.
• Free items (freeQty on PharmaceuticalBillItem): complimentary units (e.g., buy 10 get 1 free promotions) recorded separately for financial reporting.
• Staff concession: staff members receive configured discount rates on pharmacy purchases.

Sale Returns and Refunds

For returned medication (unused, wrong item, patient refusal):

1. Navigate to Sale Return (for retail) or Issue Return (for ward issues).
2. Select the original bill or search by patient/date.
3. Enter the items and quantities being returned. Batch is auto-populated from the original dispense.
4. A credit bill is generated. Stock is reinstated to the originating batch.
5. Refund is processed by cash, card credit, or credit to the patient's deposit account.

Supplier Payment

Purchases from suppliers (via GRN) generate payable amounts. Supplier payments are processed through:

Main Menu → Pharmacy → Procurement → Supplier Payment (SupplierPaymentController)

• Outstanding GRN payables are listed per supplier.
• Payment amount is entered and confirmed.
• A supplier payment bill is generated and the payable balance is reduced.

Pharmacy Bill Search

All pharmacy transactions are searchable through:

Main Menu → Pharmacy → Reports → Bill Search (PharmacyBillSearch)

Filter criteria: date range, bill type, patient, department, payment method, cashier.

Technical Reference

Item	Detail
Pharmacy bill entity	com.divudi.core.entity.PharmacyBill
Bill item entity	com.divudi.core.entity.pharmacy.PharmaceuticalBillItem
Pre-settlement controller	PharmacyPreSettleController
Sale controller	PharmacySaleController, PharmacyFastRetailSaleController
Sale return controller	SaleReturnController
Issue return controller	BhtIssueReturnController, IssueReturnController
Supplier payment	SupplierPaymentController
Bill search	PharmacyBillSearch
Related	Pharmacy Dispensing Workflows, Finance Credit Company Bill Settlement