Match Member-Pharmacy Claims Against PBM Remittances and DIR Recoupments Automatically
A PSAO processes claims payments for many member pharmacies at once, each against its own PBM contract. Kosh AI reconciles all of it without a separate manual process per pharmacy.
A remittance line only closes the loop once it's tied back to the pharmacy and claim it was meant to pay.
Retroactive fee clawbacks arrive weeks or months after the original claim, long after the payment looked final.
A claim paid below the contracted rate looks routine until it's added up across a full network.
A PBM audit request is easier to answer when the claim, remittance, and recoupment are already linked.
A PSAO managing hundreds of member pharmacies needs one view, not hundreds of spreadsheets.
Four steps that take a PBM remittance from arrival to a reconciled, network-wide view.
What a PSAO needs from reconciliation changes with network size and how claims are processed.
Keeping reconciliation consistent across a smaller, growing group of member pharmacies.
Rolling up claim-level reconciliation across hundreds of independent pharmacies without losing pharmacy-level detail.
Bringing a new member pharmacy's claims into reconciliation without a separate manual setup.
Confirming that recoupments and remittances match contract terms across every PBM relationship.
Keeping a claim-to-payment trail ready before a PBM audit request arrives.
Seeing which claims were underpaid or incorrectly recouped without chasing the PSAO for detail.
Pharmacies billing mostly through one PBM, where reconciliation still needs to catch recoupment timing.
Pharmacies juggling several PBM contracts, each with its own remittance format and recoupment schedule.
Pharmacies where manual claim-by-claim review stopped being realistic a while ago.
One reconciliation view across every member pharmacy, with pharmacy-level detail still available.
Every PBM remittance is checked against the contract, not skimmed for obvious errors only.
Retroactive fee adjustments are linked back to the claim they affect, not left as unexplained deductions.
Claim-to-payment trails are ready before a PBM audit request even arrives.
A new member pharmacy's claims join reconciliation without a separate manual process.
Claims and remittances match automatically, so finance teams spend time on variances, not routine posting.
Kosh AI connects directly with all major banks and ERPs, enabling real-time data sync for faster, more accurate reconciliations—no manual uploads, no delays.
Spotting a real underpayment or a misapplied recoupment across a whole pharmacy network takes more than eyeballing line items. Kosh AI learns which variances are routine and which ones are worth chasing.
Ties a DIR, GER, or BER adjustment back to the original claim automatically, even when it lands months later.
Spots which PBMs and claim categories keep generating the same underpayment, instead of treating each one as a one-off.
Keeps a single reconciliation view across every member pharmacy without losing pharmacy-level detail.
Builds the claim-to-payment trail as reconciliation happens, so an audit request never means starting from scratch.
PSAO reconciliation software matches claims submitted by member pharmacies against the remittances issued by each PBM, checking the paid amount against contracted reimbursement terms and flagging anything that doesn't line up. It also tracks DIR, GER, and BER recoupments, the retroactive fee adjustments that arrive weeks or months after a claim was already paid, and links each one back to the claim it affects.
Done manually, this usually means a finance team working pharmacy by pharmacy, PBM by PBM, trying to piece together which claims were underpaid and which recoupments actually match the contract. A single pharmacy's variance might be small, but across a network of hundreds of member pharmacies, those gaps compound into real, recoverable revenue that often goes unclaimed simply because no one had time to chase it down.
Kosh AI's PSAO reconciliation software matches claims to remittances automatically, links recoupments to their original claims, and rolls everything up into one network-wide view, so an underpayment surfaces while there's still time to appeal it.
Reconciling claims pharmacy by pharmacy can work for a small network. See what changes at scale.
| Feature | Automated PSAO Reconciliation | Manual PSAO Reconciliation |
|---|---|---|
| Claim Matching | Matched automatically across every member pharmacy. | Checked pharmacy by pharmacy, PBM by PBM. |
| DIR Recoupment Tracking | Linked back to the original claim automatically. | Often treated as an unexplained deduction. |
| Underpayment Detection | Checked against contract terms for every claim. | Usually catches only the obvious gaps. |
| Network Rollup | One view across the whole network. | Rebuilt manually from pharmacy-level spreadsheets. |
| Audit Readiness | Claim-to-payment trail built continuously. | Reconstructed from records after an audit request. |
| New Pharmacy Onboarding | Added to reconciliation with no new setup. | Often means a new manual tracking process. |
A PSAO managing claims for dozens or hundreds of member pharmacies runs into the same handful of problems once volume grows:
A PSAO outgrows manual, pharmacy-by-pharmacy reconciliation at a few predictable points.
A PSAO adding member pharmacies faster than its reconciliation process can keep up with.
Networks where member pharmacies bill across several PBMs, each with its own remittance format and recoupment schedule.
Networks seeing a steady stream of recoupments that are hard to trace back to the original claim by hand.
PSAOs that need a claim-to-payment trail ready at short notice, not assembled after the request arrives.
A few habits keep reconciliation accurate as a pharmacy network grows.
Bring a recent PBM remittance file to the call. We'll show you how Kosh AI would have matched and reconciled it automatically.
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