# 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](Finance-Credit-Company-Bill-Settlement.md)).

## 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](Pharmacy-Dispensing-Workflows.md), [Finance Credit Company Bill Settlement](Finance-Credit-Company-Bill-Settlement.md) |