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Reliable Group

For pharmacy benefit managers

Missed PA clocks, slipping call guarantees, unreconciled rebate payments.

As your AI operating partner, we measure one help desk, PA or rebate team, then rebuild and run its hand work.

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Table of where money, time and risk sit in PBM operations. COO call guarantees: rejects worked by hand while the pharmacy holds, rebuilt so automation enters only the overrides plan rules allow, each logged. COO PA clocks: faxes keyed by hand, rebuilt so AI reads faxes and automation flags each case before its deadline. CEO renewals: benefit coding misses found at the counter, rebuilt with test claims before every go-live. CEO audits: hand steps with no record of the rule applied, rebuilt so each automated step is logged. CFO cost to serve: help desk calls from failed file loads, rebuilt so files are checked on arrival and errors routed. CFO rebate dollars: invoices and payments matched by hand, rebuilt so automation builds invoices and logs disputes.
Who feels each problem, where it sits today, and who takes it once rebuilt.

Potential scope, confirmed in discovery

Where the hours go

  • Call guarantees missed in the January surge.

    Refill too soon and plan limit rejects fill the line. Automation enters overrides plan rules allow, each logged; agents take the rest.

  • Part D PA clocks that auto-forward to the IRE.

    Fax and ePA requests keyed by hand, statements chased. AI reads the fax; automation tracks each Part D, Medicaid or state clock.

  • Benefit misses clients remember at renewal.

    Benefit grids and formulary changes coded by hand. Automation runs test claims before go-live and flags claims to reprocess.

  • Help desk cost from files that never loaded.

    Failed eligibility loads become member not found rejects at the counter. Automation checks each eligibility and accumulator file on arrival, routing errors.

  • MAC appeals racing each state's window.

    Appeals logged and invoice cost compared to the MAC rate by hand. Automation does both and tracks each state's window; pricing decides.

  • Rebate dollars stuck in late invoices and disputes.

    Rebate invoices, payment matching and audit claim pulls done by hand. Automation builds invoices, matches payments and logs each disputed line.

Flow diagram of where Part D PA clocks slip. Steps done by hand today, each marked with who takes it once rebuilt: the fax or ePA request read and keyed, and the prescriber statement chased, go to AI; clock tracking and flagging each case early go to automation; your clinical team decides the PA.

Call guarantees and PA clocks slip

On a reject, a pharmacy tech holds while an agent works the code. For Part D coverage determinations, as of 2026, a standard request is due in 72 hours, an expedited one in 24, and a miss goes to the IRE.

  • Plan-rule overrides only, each logged
  • DUR rejects go to your pharmacist
  • Every Part D PA clock tracked

Medicare distribution, anonymized

Healthcare services

Commissions, HR and onboarding rebuilt while the business grew

A field marketing organization placing Medicare plans for 225,000+ lives through roughly 1,500 agents. Reliable Group rebuilt commissions, HR and onboarding around automation and AI, and gave agents a voice assistant for plan comparison and compliance. Sales capacity held and the business grew through the year, while the corporate team went from about 450 to under 200.

Grew, capacity held

One year: the business grew and sales capacity held. The corporate team went from about 450 to under 200.

anonymized realized

No PBM engagement is published yet. This Medicare distribution case is closest to a PBM help desk reject queue; other workflows here are potential scope.

  • Growth and sales capacityanonymized realized

What transfers: High-volume, rules-driven queues rebuilt with automation first and people on exceptions, the pattern behind help desk, override and rebate work.

See the measured results

Questions PBMs ask

  • Through lines you already track: help desk cost per call, January overtime and temp staff, performance guarantee penalties paid to clients, reprocessing, and rebate dollars invoiced late or in dispute. The discovery measures which lines one team drives and prices each rebuild in hours.

  • One fixed fee for a six to eight week discovery of one team, agreed and signed before we start. You get a workflow map and a fixed-price proposal for the first build, then build it yourself, have us build and run it, or stop.

  • At intake, completeness and the clock. We key fax and ePA requests, chase the supporting statement on exceptions and flag each case before its deadline. Approvals come from staff you authorize, under your protocol; denials, DUR and formulary stay with your pharmacists, physicians and P&T.

  • For the rule-based codes, yes. A refill too soon override for a vacation supply is entered only where your plan rules allow it, and logged; a DUR reject goes to your pharmacist. The discovery times each code and reports ASA, abandonment and first call resolution.

  • Yours, with only the access your contracts permit: the adjudication platform, often green-screen, the PA case system, ePA queues and the fax server. The discovery lists each client and program term on where work is done and who sees PHI; your compliance team signs off.

  • Each automated step logs what was read, which rule applied and what was entered. Your team owns rule changes, such as a new state window, and signs off before the build changes. Case files stay in your PA system, where client oversight and CMS program audits look.

Sources for the rules and deadlines on this pagechecked November 1, 2026

Rules change and vary by program, state and contract. Your compliance team confirms what applies to you.

How we handle regulated data

Design posture, not certification

Request documentation
BAA
Where a department handles protected health information, we execute a business associate agreement before Trace is installed or any data is accessed.
HIPAA
We execute a Business Associate Agreement before any engagement that touches PHI, and PHI is accessed only inside client-controlled systems by named individuals. Our first healthcare engagement under BAA is in progress.
Posture
Ready and aligned describe design posture, not certification. Reliable Group does not currently hold SOC 2 or ISO 27001 certification; our teams operate inside client-certified environments under client controls.
Notice
We deploy Trace only after your organization has given team members the written notice required in your state; we provide the notice template.

Your client-specific workflows, data and documentation are yours. Trace is Reliable Group software, licensed under the engagement; third-party tools keep their own license terms.

Last reviewed October 2026

Next step

Stop guessing how your operation works.

Tell us which department eats the most hours. We will say candidly whether measuring it is worth it.

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