CareMetx Solutions: The Broadest Range of Services for Radically Efficient Patient Access

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Patient transactions in a year *

CareMetx Solutions: The Broadest Range of Services for Radically Efficient Patient Access

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Patient transactions in a year *

At CareMetx, we put patients first. Facilitating the patient journey is at the heart of everything we design. Whether you’re looking to upgrade a single function or overhaul your entire hub operation, each of our technology-enabled eService modules is designed to support today’s complex access ecosystem with agility and radical efficiency. Click on any category to learn more.

Practical Solutions That Get Patients on Therapy Faster

86% of healthcare providers say administrative burdens for their office are high or extremely high¹. The result? In a given year, one in four patients experience a prior-authorization related delay in receiving treatment².

That doesn’t have to be the case for patients on your therapy. At CareMetx, we bring together highly skilled teams and real-time data, resulting in practical, efficient workflows and facilitating a 33% improvement in time to therapy³.

Your CareMetx case managers are carefully selected for their sincere dedication to serve patients who might be feeling overwhelmed- not just by their diagnosis, but by all the administrative navigation that comes along with it. CareMetx teams are equipped with automated technology that can radically speed patient access to therapy.

Let’s work together to provide greater support to patients using your therapy and the providers who treat them. Armed with data, these providers will be better equipped to provide care and facilitate timely access to your treatment.



Engagement Channels

  • Healthcare provider portal
  • Field portal
  • Embedded provider workflows (EMR, PMS, patient apps, etc)

Automated Transactions

  • eBV (medical and Rx)
  • ePA (medical and Rx)
  • eEnrollment/consent
  • Copay (medical and Rx)
  • ePAP

CRM, Telephony, and Analytics

  • Purpose-built case management system
  • Fully integrated data across engagement channels; telephony and data captured in CRM
  • Integrated with cloud-based enterprise telephony platform
  • Enterprise data lake for advanced reporting and analytics


  • Customer support
  • Benefit verification
  • Prior authorization and appeal support
  • Copay enrollment and adjudication
  • Pharmacy triage
  • Provider experience teams
  • Field reimbursement teams
  • Nursing support
  • Claims review



Virtual Call Centers Built Across the Nation

  • 100% remote training and hiring
  • Hire the best, regardless of location
  • Training certification programs built for a virtual team


²Kevin B. O’Reilly, News Editor. (2017, January 30). Survey quantifies time burdens of prior authorization. American Medical Association. Retrieved December 10, 2021, from

³73494 – QBR Deck PPT 12/31/21

Helping Patients Navigate Affordability Challenges

Every year, patients delay or forgo therapy because of cost. The unfortunate reality is that many of those patients qualify for financial support, they just aren’t sufficiently guided through the process of obtaining it.

At CareMetx, it’s our mission to make it easier for providers and patients to understand and access financial support. As our client, you can select services that range from end-to-end Copay and PAP Administration, to specialized Bridge Dispensing Programs and more.


Automated Transactions

Medical Copay
Our Medical Benefit Copay programs utilize the medical billing and payment systems used within provider offices. We support electronic or paper submission with custom business rules to provide financial support to patients.

Pharmacy Copay
Virtual copay card with electronic claim adjudication and settlement has the ability to electronically accept enrollments, render real-time eligibility decisions, and deliver copay adjudication via POS, EFT, and virtual debit cards.

Assessment and eEnrollment for patients seeking financial assistance has the ability to accept enrollments, render real time eligibility decisions based on income, LIS status, and other brand-specific criteria.


Engagement Channels

Digital—Provider Portal

  • The CareMetx provider-facing portal can be configured to assess and enroll qualified patients into copay and financial assistance programs
  • Innovative solutions such as our MedeCopay provide better alternatives to traditional paper-based, manually driven copay programs

Alternative Channels—Phone/Fax/Mail

  • The CareMetx service model can also support more traditional channels for copay/affordability management

Modern Solutions to Adherence Challenges

When it comes to specialty illness treatment in particular, adherence is not as simple as it may be for other, less complicated care. Adhering to specialty care may mean traveling miles to receive treatment at an ambulatory infusion center. It often means navigating complex authorizations and benefit verifications back-and-forths in order to prevent thousands in personal cost responsibility. Put simply- it means far more than picking up a bottle of pills from a local pharmacy and remembering to take them every day.

At CareMetx, we know that starting therapy is a critical step for patients trying to get well. That’s why we have introduced new industry standards that address these specific challenges, and assist patients in accessing your specialty therapy brands.

For one, our technology and eService transactions materially reduce administratie roadblocks that delay or prevent patients from starting treatment. Furthermore, our innovative affordability solutions make it fast and easy for patients to enroll in financial assistance programs.



Our 2021 acquisition of Human Care Systems (HCS) then added Resilix® to our suite of adherence-specific services.

Resilix is purpose-built for biopharma Patient Services and delivers visibility and control over the full set of patient services touchpoints. Resilix delivers a seamless patient experience, including coordination among phone, field, reimbursement, and digital touchpoints.

At its core, Resilix is built to optimize the experience for each user: patient, caregiver, healthcare professional, call center representative , field representative, reimbursement specialist, and fulfillment specialist. 

Learn more about the CareMetx Digital Hub—schedule a demo today!

See how CareMetx Digital Hub can get patients on therapy faster

The Digital Standards our Healthcare Landscape Demands

When a provider prescribes a specialty therapy, the next steps often involve a complex navigation of authorization requirements that patients must meet in order to access their care. This onslaught of paperwork and phone calls often causes delays that can threaten continuity of care- which is especially troubling for patients with the kind of complex diagnoses that would require a specialty therapy in the first place.

While each patient is unique, they all share a common desire to get better, fast. CareMetx’s eService transactions ensure that these notorious administrative pretreatment hurdles are streamlined and simplified- enabling patients to quickly begin receiving care.

Journey graphic

CareMetx is not only the industry leader in automated Benefit Verifications, but we also perform manual Benefit Verification services more accurately and efficiently than our competitors. Our proprietary process combines our extensive payer connectivity and rules engine with specialized benefit verification team members to generate scalable benefit verification results that are consistently 2x more efficient than industry standards.

Greg Morris, Chief Strategy Officer


Engagement Channels

Provider Portal

  • A provider-facing digital asset purpose built to enable self-service patient access solutions
  • Configurable services architecture, based on client specifications and desired patient access experience
  • Integrated smart “off-ramps” ensure high-touch patient services engage when necessary

Field Portal

  • A web portal designed to deliver brand-specific benefit and usage intelligence around key metrics associated with access, patient and provider activities, and reimbursement
  • Empowers Field Sales with actionable reimbursement insights and timely data to effectively engage providers and patients

Embedded Provider Workflows

  • Specific use cases where providers directly access CareMetx e-transactions to perform service requests from their native technologies (EMR, PMS, etc.)

Learn more about the CareMetx range of eServices—schedule a meeting today!


Real-Time Transactions

Medical eBV

Product-specific, automated medical benefit investigation

10+ years in market; most-proven transaction of its type; integrated with on-demand, high-touch services

Medical ePA

Closed-loop digital process for completing a medical prior authorization

Ability to access payer requirements, complete and electronically submit prior-authorization

Medical Copay

Supports electronic or paper submission with custom business rules to provide financial support to patients

Our Medical Benefit Copay programs utilize the medical billing and payment systems used within provider offices.

Pharmacy eBV

Real-time benefits transparency for pharmacy-covered brands

Delivers benefits information for products covered under commercial policies and robust, additional details for Medicare patients

Pharmacy ePA

Quickly understand and address prior authorization requirements

Fully digital experience for PA request, submission, and response

Pharmacy Copay

End-to-end pharmacy copay solution

Transforms front-end business processes for candidate assessment and enrollment to accelerate workflows and improve operational outcomes.


Complete a manufacturer/brand-specific eEnrollment form and capture consent via eSignature

Simplifies provider workflows, eliminates manual forms, reduces amount of bad data; increases number of patients enrolling in Hub services


Integrated assessment and eEnrollment for patients

Digitally integrates candidate assessment for PAP into existing Hub workflows

Learn more about the CareMetx range of eServices—schedule a meeting today!


CRM, Telephony, and Analytics


Purpose built for patient services

Flexible data and workflow architecture that grows with your program and integrates directly with our real-time transactions, ultimately driving toward a workflow model that leverages automation and enables Case Managers to focus on complex cases.


Enterprise-grade, cloud-based telephony platform with multichannel capabilities

Deeply integrated with our CRM to allow for multichannel inputs via phone, fax, or chat interfaces that are intelligently routed to our case management teams.

Data Analytics and Integration

Robust data architecture built on an enterprise-grade data lake, allowing for data interchange and robust analytics

Our data lake serves as a foundation to drive detailed patient journeys and program performance analytics, leveraging enterprise business intelligence tools and real-time API-based data interchanges.

Bringing all Healthcare Stakeholders to the Table

Competing interests can present challenges for manufacturers seeking to align stakeholders and improve access to therapies. Providers are looking for an efficient way to onboard and manage patients requiring therapy. Manufacturers are interested in removing barriers to patient access. Payers are focused on cost containment. Patients want timely access to their therapy, and support during a confusing and scary experience.

CareMetx can deliver novel solutions that align the interests of all stakeholders through 3 unique offerings.

Learn more about CareMetx OutcomeRx— schedule a meeting today.


Therapy Management Solutions

Patient Support Services

Our solution combines the best health and data technology with high-touch stakeholder engagement to fully support the provider, payer, and patient from initial therapy administration, tracking along the continuum of care to wellness.

Financial Solutions

CareMetx OutcomeRx helps manufacturers align their interests with the payers by offering financial and insurance products to support innovative, value-based models.

Technology Solutions

Proprietary technology to guarantee high-touch patient experiences and seamless logistics for cell and gene therapies.

Posttherapy Patient Monitoring​

Specialized, expert human resources matched to the therapy’s unique patient journey.​

Data Capture for FDA Requirements

Data monitoring and FDA-mandated outcomes reporting tools to engage with the providers, patients, and payers throughout the patient’s experience over time.

Value-Based Contract Administration

Value-based contract administration and adjudication to ensure patient results are achieved.


Next-Generation Outcomes-Based Contract

A therapy warranty works much the way a new car warranty does. You buy the car from the dealer and the manufacturer warranties the core components of the vehicle. The car owner holds the warranty in the event one of the core components breaks down during the warranty period. The manufacturer repairs the part rather than paying the owner a rebate for the part.

The therapy warranty establishes an insured warranty for clinical interventions against potential adverse outcomes. The warranty pays for an alternative therapy should the warrantied therapy established target metrics/endpoints go unmet. In this way the warranty promotes payer adoption, an important barrier to access, and eases coverage rules.


Patient Access to Costly and Curative Therapies (PACCT)

Carve-Out Insurance for Uncovered or Partially Covered, High-Cost Therapies, Diagnostics, and Devices

Patient Access to Costly and Curative Therapies (PACCT) promotes patient coverage by filling a key gap in reinsurance for costly therapies. We believe that using first dollar reinsurance coverage will increase payer adoption by improving risk predictability.

  • Underwriting/rating performed per covered plan with rates for commercial and Medicaid plans
  • Backed by A-rated carriers: Crum & Forster and Liberty Mutual
  • Distributed through payers, TPAs, reinsurance, and stop-loss carriers

Learn more about the CareMetx Digital Hub—schedule a demo today!

See how CareMetx Digital Hub can get patients on therapy faster

*CareMetx Impact Data report, April 2020 - March 2021