NHS claims and reimbursement

• Every branch's Schedule of Payments is read and reconciled each month against the dispensing and clinical systems, not a sample.
• Services recorded but not claimed are flagged to the branch daily, with the deadline, while the claim can still be made.
• The gap between expected and actual payment is explained in plain English: price, volume, missing claims or adjustments, each linked to the source line.
• Purchase prices from wholesaler invoices are matched to reimbursement item by item, so buying sees loss-making lines and concession candidates early.
• Finance gets a cash forecast per branch and for the group, updated as concessions and Category M changes are announced.
• People make every claim and every correction. The AI finds and explains; it never submits or amends anything.

• DHSC / NHSBSAThe Drug Tariff: reimbursement prices (Parts V and VIII)
  →

  Category M prices change each quarter, Category H prices change each quarter on a different cycle, and price concessions apply only to the month they're granted. Prices are held as dated reference data, and every check uses the price that applied in the month of dispensing, including any discount deduction or exemption.

• NHS England / NHSBSAPharmacy First service specification and Drug Tariff Part VIC
  →

  Consultations flow from an approved clinical system, through an API, into Manage Your Service. Since 1 June 2025, a claim must be made by the end of the month after the consultation, and later claims aren't paid unless a proven IT fault caused the delay. Monthly caps apply by band, and the fixed payment depends on minimum activity and on signing up to linked services. So the design compares the clinical system with MYS every day, not at month end.

• NHS EnglandNHS Terms of Service and the monthly FP34C submission
  →

  Each branch declares its prescriptions through MYS by the 5th of the month, or the 6th when a bank holiday falls in the first five days, to get the earlier advance payment. Claims must be accurate: claiming for something not supplied or not delivered is fraud. The AI finds gaps and explains them. It never creates, submits or changes a claim.

• ICO / NHS EnglandUK GDPR, the Data Protection Act 2018 and the DSPT
  →

  Matching services to claims touches patient-level health data. Match on pseudonymised references where possible, leave identifiable data in the source systems, process in UK regions, and fit the platform inside each branch's Data Security and Protection Toolkit assurance.

• HMRCVAT records and Making Tax Digital for VAT
  →

  Wholesaler invoices and credit notes feed both margin and VAT. Keep extracted invoice data linked to the original document, and leave VAT treatment and returns to the existing finance system.

On a phone, the table shows the platform you pick. Sovereign / on-prem means open, portable components you can run in your own data centre or with a UK or European provider; IONOS is shown as one example, and others exist. What sovereign cloud means →

• A reimbursement team owns the exception queue, ordered by deadline first and value second.
• A clear rule that branches fix claims and the AI never does, written into the branch SOPs.
• A monthly variance review with finance and buying, including lines that lost money and concessions requested.
• A named owner for the reference data: Drug Tariff prices, concessions and categories, loaded and checked each month.
• Branch teams trained on what each task means and how to fix it in MYS or the clinical system.
• A simple way for branches to mark a flag as wrong, fed back into the rules each month.

1. 3 weeks

   Discovery

   Take ten branches' last six months, measure what went unclaimed or unexplained, and confirm access to the dispensing system, clinical systems, MYS outputs and invoices.

2. Gate · must be true to passA baseline value agreed with finance, data access confirmed, DPIA started, and information governance involved.

3. 8 weeks

   Pilot

   Thirty branches: back-test on six past months, then run live through two month-ends, with the daily services check sending real tasks.

4. Gate · must be true to passFlags accurate within agreed limits, variance explained above the target, and finance sign-off.

5. 4–6 weeks

   Production

   All branches for the services check and the monthly reconciliation, with the cash forecast going to finance.

6. Gate · must be true to passMonitoring, support model, reference data ownership and branch training in place.

7. Ongoing

   Scale

   Add new services as they launch, link purchase prices to buying decisions, and prepare the invoice feed for e-invoicing.

8. Gate · must be true to passEach addition passes the same accuracy and false-flag checks.

R ResponsibleA AccountableC ConsultedI Informed· not involved

Where I'd fit

1. 1

   Goes wrong

   The reconciliation finds lost money after the claim window has closed.

   How the design avoids it

   Check services daily against MYS, and send each branch a task with the deadline on it.

2. 2

   Goes wrong

   A language model does the sums, and occasionally gets one wrong.

   How the design avoids it

   Tested code calculates every expected payment from dated reference data. The model reads documents and explains.

3. 3

   Goes wrong

   Concessions arrive late, so every month-end forecast is wrong.

   How the design avoids it

   Forecast with a range, mark concession lines as provisional, and update when the price is confirmed.

4. 4

   Goes wrong

   Branches get hundreds of flags and stop reading them.

   How the design avoids it

   Rank by deadline and value, group by cause, and measure how often flags are wrong.

5. 5

   Goes wrong

   Nobody can get the NHSBSA data out automatically, and it's found out late.

   How the design avoids it

   Confirm formats and access in discovery. A named person and a watched folder is fine.

1. Branch by branch, from 29 October 2026
   Independent prescribing in Pharmacy First and the contraception service

   Legally available from 29 October 2026, starting branch by branch once the ICB approves each one. New consultation types, a one-off £500 set-up payment and £525 a month for infrastructure, with prescribing consultations counting towards the Pharmacy First thresholds. Add them to the reconciliation before the first claims, not after the first missing payment.

2. Quarterly, next in December 2026
   More medicines moving into Category H

   Nineteen products had moved by September 2026, priced from lagged market data. Keep each product's Drug Tariff category as dated reference data, so a move changes the forecast without code changes.

3. 2027/28 onwards
   Reform of the pharmacy contract, funding and reimbursement

   Community Pharmacy England accepted the 2026/27 settlement on condition of joint work with government on alternative contract, funding and reimbursement models. Keep fees, caps and margin rules as configuration, not code.

4. April 2029
   Mandatory e-invoicing for VAT invoices

   HMRC published its roadmap on 28 October 2026: a Peppol-based model, a technical consultation in spring 2027 and readiness testing from summer 2028. Wholesaler invoices will arrive as structured data, so design the purchase-price feed to take e-invoices, with document reading as the fallback.