The Complete PBM Operations Platform

From document intake to determination letter. From formulary management to medication adherence. One platform, AI-powered, configurable per PBM hierarchy.

Capabilities

Every domain. One platform.

Purpose-built for PBM clinical operations. Each domain is deeply integrated, not bolted on.

Prior Authorization

Full lifecycle management: intake, questionnaire, clinical review, AI assessment, decision, appeal, acknowledgment. SLA monitoring with breach alerts. Determination letters with KMS encryption.

AI Clinical Intelligence

8 AI capabilities in production. 3-tier clinical assessment, document intelligence triage, clinical AI chat, OCR entity matching, configurable prompt registry, and real-time AI operations dashboard.

ePrescribing (NCPDP SCRIPT)

Real-time electronic PA via Surescripts. 12 transaction types, XML serialization/deserialization, ePa Operations Dashboard. CMS 2026 compliant.

Formulary Management

Medispan 500K+ drug catalog integration. Hierarchical formulary association, NDC-to-GPI resolution, drug tier management, quantity limits, step therapy groups.

Medication Adherence

PQA-defined PDC calculation engine (PDC-DR, PDC-RASA, PDC-STA). Star Ratings monitoring, intervention documentation, prescriber adherence reporting.

Prescriber Management

NPPES NPI lookup, SAM.gov exclusion screening, batch import, outreach campaigns with conversion funnels, delegate management.

Claims Processing

Batch upload (CSV/TSV/ZIP), per-record error review, claims transaction loading and reconciliation.

Platform Configuration

7-level hierarchy (System > PBM > Health Plan > Customer > Client > Group > Plan). Per-tenant database isolation, configurable controls for every operational parameter.

Architecture

Built different. On purpose.

Multi-Tenant Isolation

Per-tenant databases, S3 buckets, and AWS resources. HIPAA-compliant by architecture, not by policy.

Event-Driven Processing

10+ SQS-backed Lambda workers for async clinical workflows. No synchronous bottlenecks in PA processing.

Serverless on AWS

Lambda, SQS, EventBridge, Textract, Bedrock, Cognito, S3, RDS PostgreSQL. Zero infrastructure management for PBMs.

7-Level Configuration

System > PBM > Health Plan > Customer > Client > Group > Plan. Lowest-level wins with locked value override.

Ready to modernize your PBM operations?

See how NexusLedge embeds AI into every clinical workflow.

See the Platform