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Claims data compared: pharmacy, payer, PBM, provider, pharma

Claims Data Compared: Pharmacy, Payer, PBM, Provider, Pharma


Highlights from a conversation with Linda Schultz, VP, Client Success at AllazoHealth. Got questions? Linda can be reached at

When it comes to the AllazoHealth AI engine, the quality of outcomes rely on a diverse data set from over 11 million lives and 600 million claims. We use pharmacy, payer, PBM, provider and pharmaceutical company data to generate insights about individual patient behavior, as well as other sources such as consumer behavior and population demographics. These data sets have different strengths and blind spots. By utilizing them all, our AI engine can reliably make a positive impact on patient behavior and health outcomes.

Pharmacy claims data

Pharmacy claims data offers a lot of detail, because it tracks medications and directions from the prescription order, to the submission for payment, to the dates medications are being filled and then picked up by the patient. It offers specific and frequent information on patient adherence and gaps in medication care, as well as information on patient and plan costs.

This data can also show demographic and population health insights. For example, some geographic areas may have higher incidence of asthma, and we can compare the data with areas with lower rates to track adherence in both.

When a patient changes health plans, pharmacy data continues to track them, providing continuity of the medication filling picture. On the other hand, if a patient switches pharmacies, payer data can fill the gaps in pharmacy data.

Payer claims data

In addition to pharmacy data, payers offer medical claims data and enrollment data. Medical claims data gives insight into patients’ health conditions, history such as hospitalizations, and gaps in care. Sometimes, medical claims data also shows lab work and testing results. All of these data points can be helpful in determining what the patterns of care are for different individuals and patient populations.

Payer data sets also track enrollment, which helps paint a fuller picture of individual patients – whether a patient is actually a member of their plan, or if they’ve chosen another.

PBM claims data

PBMs have access to all the data that a pharmacy would have. But in addition, because they manage prescription-based care, they have a great deal of data about drug utilization, formulary structure and benefit design.

Utilization management ensures that the right drug gets prescribed for the right patient and condition, at the right time and duration. That utilization management information is built by the PBMs into the processing of a claim. In addition, formulary placement, and how the pharmacy benefit is designed with regard to cost structure to the patients and the plan, is captured in PBM data.

Provider data

Data that comes from provider groups can contain both medical and pharmacy claims data depending on their sources. Often it is more complex to obtain since sources may be from both internal and external organizations, like Departments of Health. This data can also be older than what would be optimal and must be evaluated on usefulness to the machine-learning output.

Pharmaceutical data

Pharmaceutical companies track prescription data to monitor sales of their products and applications of their patient and provider-focused programs. Usually this data is obtained from third parties, and is a less complete picture because they often don’t have a direct engagement with the patient.

About AllazoHealth

AllazoHealth uses artificial intelligence to make a positive impact on individual patient behavior. We optimize medication adherence outcomes for pharmaceuticals, payers, and pharmacies. Our AI engine targets the right individual patient with the right intervention at the right time.

Find out more about how AI benefits patient adherence. Contact us today.   

Learn more about the impact of AllazoHealth's technology


Improving the Effectiveness of Adherence Interventions by


We worked alongside Blue Cross Blue Shield of North Carolina and their call center vendor to launch one of our biggest programs, working to improve adherence rates across their population of 104,392 Medicare Advantage Part D (MAPD) patients. We found that AllazoHealth targeted interventions accounted for 5.45 times the uplift in adherence compared to traditionally targeted interventions.