Survive the audit that could end the business.

Name: PBM Audit Defense — SSVP AI
Brand: SSVP AI

Proactive: a daily exposure queue ranked by dollars-at-risk. Reactive: parse the notice, map each discrepancy code to its required documents, pull them from PrimeRx, reconcile invoices to dispensed units by NDC, and assemble a per-claim package with a cover rebuttal. The discrepancy-code → defense-document mapping is the product.

MODEProactive + ReactiveINPUTAudit notice · claim & doc stateOUTPUTExposure queue · defense packageMOATPayer-rule knowledge base

TODAY VS. WITH SSVP

What changes the day it installs.

Today — the manual way

An audit notice lands with a two-week clock and no system to answer it.
Documents are hunted one claim at a time, by hand, under pressure.
Invoice-to-dispensed reconciliation is a spreadsheet nightmare.

With SSVP

A daily queue ranks exposure by dollars-at-risk before any notice arrives.
The reactive agent maps every discrepancy code to its required documents.
Invoice-to-dispensed reconciles by NDC; the package assembles itself.

Same counter, same PrimeRx, same pharmacist in charge — the keystrokes just stop being yours.

THE AGENTIC LOOP

Perceive. Reason. Act. Verify.

Four steps, every time. The agent handles the first three; a licensed pharmacist handles the last.

01
Rank the exposure
Daily, the proactive agent scores claims by dollars-at-risk — threshold claims, DAW without docs, early refills, NDC drift, missing signatures.
02
Parse the notice
A reactive audit notice is read once; each discrepancy code is mapped to the documents that answer it.
03
Assemble the package
Documents pull from PrimeRx via vision + UIA; invoices reconcile to dispensed units by NDC; a per-claim package and cover rebuttal compose.
04
Sign and send
Gaps are flagged, the clock is tracked, everything is logged. The pharmacist reviews and signs off.
PHARMACIST SIGNED

The machine never signs. A licensed pharmacist does — every write is read back and compared before it counts.

THE INSTRUMENT

Every discrepancy code, mapped to the document that answers it.

This mapping — code → required documents — is the product. Pick a finding, or press Play all to walk the nine.

Discrepancy Mapper

Finding 01

Missing/invalid hardcopy

PBM alleges

No valid original prescription on file

Agent produces

Original Rx image, or e-prescription transmission record

Every code maps to the exact documents that answer it — pulled from PrimeRx, reconciled to invoices by NDC, and assembled into a per-claim package. In plain terms: when the auditor points at a claim, the paperwork that clears it is already built.

WHAT GETS A PHARMACY AUDITED

Ten signals PBMs watch.

Not fear-mongering — just the patterns that pull a claim into review. The proactive queue scores your book against every one of them, daily.

High-dollar & high-cost-drug claimsEarly refills & refill-too-soon patternsDAW code usageCompounded prescriptionsSingle-prescriber concentration spikesBrand dispensed where a generic existsQuantity & days-supply outliersHigh volume on a specific NDCFrequent reversals & rebillingCopay-collection inconsistencies

Plain version: these are the things that make a PBM come knocking. SSVP watches them for you, before the notice ever arrives.

WHAT IT RETURNS

The numbers it hands back.

$26,144avg PBM audit recoupment

< 2 wkstypical window to respond

$24,314avg a prepared pharmacy avoids

UNDER THE HOOD

Why this one holds up.

Two agents, one knowledge base

Proactive ranks tomorrow's exposure; reactive answers today's notice. Both drink from the payer-rule KB — the asset human incumbents took decades to build.

The mapping is the moat

Each provider manual, each discrepancy-code documentation standard, each appeal procedure. Every audit handled enriches the base.

The defensible asset here isn't the vision plumbing; it's the PBM-rules knowledge — each provider manual, each discrepancy-code documentation standard, each appeal procedure, and the state audit protections that override them. That is what the human incumbents spent decades building. Budget for it as a knowledge-engineering effort as much as an AI one — but note that it compounds: every audit handled enriches the rules base, which is precisely what makes the business defensible over time.

ONE ENGINE, FIVE MODULES

It doesn't work alone.

Typing feeds clean claims; clean claims plus live inventory feed audit defense; the same inventory feeds ordering; insurance capture tells every module which PBM it's dealing with. A competitor cannot reassemble this from parts.

MOD 01/05IN BUILD