Tmesys® Pharmacy Network
Tmesys, an affiliate of Optum Rx, is a national, wholly-owned workers’ compensation-specific network consisting of nearly 60,000 retail pharmacies, home delivery, and specialty pharmacies.
The Tmesys Network provides:
- Nationwide online claims submission
- Approval and processing for state and federal workers' compensation claims
- Approval and processing for certain automobile no-fault / personal injury protection claims in select states
Fraud, Waste, and Abuse
Tmesys is committed to complying with applicable Fraud, Waste, and Abuse (FWA) standards, and to implementing and enforcing policies that help identify and stop FWA and actions that promote FWA. Therefore, all Tmesys Network Pharmacy Providers should familiarize themselves with the FWA provisions in the Provider Manual which can be reviewed here: https://professionals.optumrx.com/resources/manuals-guides/provider-manual.html.
In general, pharmacy transactions processed through the Tmesys network can be adjudicated within either an open network, such as those involving state workers’ compensation claims, or a closed network, such as transactions involving federal workers’ compensation and other federal programs.
When a pharmacy agrees to process a transaction through our open network, the pharmacy agrees to the payment terms and other conditions established and updated by Tmesys.
For transactions within a closed network, the injured worker must use a Tmesys Network Pharmacy in order to obtain the prescription medication and adjudicate the claim. Tmesys Network Pharmacy Providers that submit claims for adjudication within the closed Tmesys federal network should ensure that they are familiar with the following:
- Tmesys reserves the right to, in its sole discretion, immediately suspend a Tmesys Network Pharmacy Provider from the Tmesys network (both closed and open networks) pending investigation into possible FWA.
- Tmesys also reserves the right to, in its sole discretion and unless otherwise agreed between Tmesys and the Tmesys Network Pharmacy, immediately terminate a Network Pharmacy Provider from the Tmesys network if the Network Pharmacy Provider does not comply with the Provider Manual or engages in behavior which risks the health and safety of injured workers, constitutes FWA, or is detrimental to the Tmesys Provider Network.
- Tmesys reserves the right to recoup any overpayments to or withhold payment from a Tmesys Network Pharmacy Provider under investigation for activities that may constitute FWA, or which is determined by Tmesys, in its sole discretion, to have engaged in activities that constitute FWA.