Systems and methods for identifying prior authorization assistance requests in healthcare transactions

• US 10,423,759 B1
• Filed: 01/16/2015
• Issued: 09/24/2019
• Est. Priority Date: 01/16/2015
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: McKesson Corp.
• Inventors: Harris, Sr., Patrick I., Pinsonneault, Roger G.
• Primary Examiner(s): Durant, Jonathan
• Application Number:
  US14/598,968
• Time in Patent Office: 1,712 Days
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G16H 20/00 ICT specially adapted for therapies or health-improving plans, e.g. for handling prescriptions, for steering therapy or for monitoring patient compliance
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

An adjudicated response to a healthcare transaction for a product or service for a patient is received and includes a transaction submission time, and transaction comparison data. The transaction comparison data can be compared to a multitude of transaction records of previously processed healthcare transactions to identify a match. The transaction submission time for each of the received healthcare transaction and stored healthcare transaction can be received and compared to one another to determine a submission time difference between the submission time for the healthcare transaction and the stored healthcare transaction. The submission time difference can be compared to a time limit threshold to determine if the difference satisfies the time limit threshold. Based on the determination that the submission time difference satisfies the threshold, the received healthcare transaction can be determined to be a request for a service, such as prior authorization assistance.

Claims

1. A computer-implemented method, comprising:

with reference to a routing table stored by data files of a service provider computer embodied by a switch or a router, determining a claims processor computer as a destination for a first healthcare claim transaction received from a pharmacy computer for a pharmacy and transmitting the first healthcare claim transaction to the claims processor computer for adjudication;

receiving, by a network interface of the service provider computer associated with a service provider and comprising one or more computer processors from the claims processor computer associated with a claims processor, a first adjudicated transaction response for the first healthcare claim transaction comprising a first patient identifier for a patient;

a first transaction submission time, and first transaction comparison data, wherein the first transaction comparison data comprises;

a first product identifier identifying a first product or service for the patient;

a first payor identifier; and

a first prescription/service reference number;

in an instance in which the first healthcare claim transaction was rejected, storing information relating to the first healthcare claim transaction in a rejected claims database in communication with the service provider computer;

with reference to a database of adjudication codes, determining, by the service provider computer and based at least on a first reject code in the first adjudicated transaction response, that a basis for a rejection of the first healthcare claim transaction was for lack of prior authorization;

modifying, by the service provider computer and based at least in part on the rejection of the first healthcare claim transaction for lack of prior authorization, the first adjudicated transaction response to include a prior authorization offer message;

receiving, by the network interface of the service provider computer from the claims processor computer, a second adjudicated transaction response for a second healthcare claim transaction, the second healthcare claim transaction comprising a second patient identifier for the patient;

a second transaction submission time, and second transaction comparison data, wherein the second transaction comparison data comprises;

a second product identifier identifying the first product or service for the patient;

a second payor identifier; and

a second prescription/service reference number;

with reference to the database of adjudication codes, determining, by the service provider computer and based at least on a second reject code in the second adjudicated transaction response, that the second healthcare claim transaction was rejected for lack of prior authorization;

identifying the second transaction comparison data for the second healthcare claim transaction;

comparing, by the service provider computer, the second transaction comparison data to data in a plurality of records of previously processed healthcare transactions stored in the rejected claims database to identify a matching healthcare transaction record comprising matching transaction comparison data exists, wherein the matching healthcare transaction record comprises the first patient identifier;

the first transaction submission time, and the first transaction comparison data from the first healthcare claim transaction;

retrieving, by the service provider computer and based at least on a positive identification of the matching healthcare transaction record, the second transaction submission time for the second healthcare claim transaction and the first transaction submission time for the matching healthcare transaction record;

calculating, by the service provider computer, a submission time difference between the second transaction submission time and the first transaction submission time;

with reference to a record containing a time threshold limit stored by the data files of the service provider computer, comparing, by the service provider computer, the submission time difference to the time limit threshold to determine if the submission time difference satisfies the time limit threshold;

determining, by the service provider computer and based at least in part on the positive determination that the submission time difference satisfies the time limit threshold, that the second healthcare claim transaction is a request for prior authorization assistance; and

modifying, by the service provider computer and based at least in part on the rejection of the second healthcare claim transaction for lack of prior authorization, a second adjudicated transaction response to include a prior authorization assistance request acceptance message.

2. The computer-implemented method of claim 1, further comprising:

wherein modifying the first adjudicated transaction response comprises appending, by the service provider computer, the prior authorization offer message to the first adjudicated transaction response, and wherein the method further comprises;

transmitting, by the service provider computer to the pharmacy computer for the pharmacy, the first adjudicated transaction response and the prior authorization offer message.

3. The computer-implemented method of claim 1, further comprising:

receiving, by the service provider computer from the pharmacy computer for the pharmacy, the first healthcare claim transaction;

receiving, by the service provider computer from the pharmacy computer, the second healthcare claim transaction; and

transmitting, by the service provider computer to the claims processor computer, the second healthcare claim transaction for adjudication.

4. The computer-implemented method of claim 1

wherein modifying the second adjudicated transaction response comprises appending, by the service provider computer, the prior authorization assistance request acceptance message to the second adjudicated transaction response;

and

transmitting, by the service provider computer to the pharmacy computer, the second adjudicated transaction response and the prior authorization assistance request acceptance message;

generating, by the service provider computer and based at least in part on the request for prior authorization assistance and one or more of the first and second healthcare claim transactions, a prior authorization assistance request; and

transmitting, by the service provider computer, the prior authorization assistance request to a prior authorization assistance computer.

5. A computer-implemented method, comprising:

with reference to a routing table stored by data files of a service provider computer embodied by a switch or a router, determining a claims processor computer as a destination for a first healthcare claim transaction received from a pharmacy computer for a pharmacy and transmitting the first healthcare claim transaction to the claims processor computer for adjudication;

receiving, by a network interface of the service provider computer associated with a service provider from the claims processor computer, a first adjudicated transaction response for the first healthcare claim transaction comprising a first patient identifier for a patient, a first transaction submission time, and first transaction comparison data;

in an instance in which the first healthcare claim transaction was rejected, storing information relating to the first healthcare claim transaction in a rejected claims database in communication with the service provider computer;

modifying, by the service provider computer and based at least in part on the first healthcare claim transaction being rejected for lack of prior authorization, the first adjudicated transaction response to include a prior authorization offer message;

transmitting, by the network interface of the service provider computer to the pharmacy computer for the pharmacy, the first adjudicated transaction response and the prior authorization offer message;

receiving, by the network interface of the service provider computer from the claims processor computer, a second adjudicated transaction response for a second healthcare claim transaction, the second healthcare claim transaction comprising a second patient identifier for the patient;

a second transaction submission time, and second transaction comparison data;

comparing, by the service provider computer, the second transaction comparison data to data in a plurality of records of previously processed healthcare transactions stored in the rejected claims database to identify a matching healthcare transaction record comprising matching transaction comparison data exists, wherein the matching healthcare transaction record comprises the first transaction submission time and the first transaction comparison data;

retrieving, by the service provider computer, the second transaction submission time and the first transaction submission time;

calculating, by the service provider computer, a submission time difference between the second transaction submission time and the first transaction submission time;

with reference to a record containing a time threshold limit stored by the data files of the service provider computer, comparing, by the service provider computer, the submission time difference to the time limit threshold to determine if the submission time difference satisfies the time limit threshold;

determining, by the service provider computer and based at least in part on the positive determination that the submission time difference satisfies the time limit threshold, that the second healthcare claim transaction is a request for the prior authorization service; and

modifying, by the service provider computer and based at least in part on the second healthcare claim transaction being rejected for lack of prior authorization, a second adjudicated transaction response to include a prior authorization assistance request acceptance message.

6. The computer-implemented method of claim 5, wherein the method further comprises:

determining, by the service provider computer and based at least on a reject code in the second adjudicated transaction response, that the second healthcare claim transaction was rejected for lack of prior authorization;

wherein comparing the second transaction comparison data to data in the plurality of records of previously processed healthcare transactions is completed based at least in part on the determination that the second healthcare claim transaction was rejected for lack of prior authorization.

7. The computer-implemented method of claim 5, wherein the second transaction comparison data comprises:

a product identifier identifying a product or service for the patient;

a payor identifier;

a prescription/service reference number;

a banking identification number, a processor control number, a fill number, a quantity dispensed, and a days'"'"' supply.

8. The computer-implemented method of claim 5, wherein the method further comprises:

transmitting, by the service provider computer to the pharmacy computer, the prior authorization assistance request acceptance message;

generating, by the service provider computer and based at least in part on the request for prior authorization assistance and one or more of the first and second healthcare claim transactions, a prior authorization assistance request; and

transmitting, by the service provider computer, the prior authorization assistance request to a prior authorization assistance computer.

9. The computer-implemented method of claim 5, further comprising:

receiving, by the service provider computer from the pharmacy computer, the first healthcare claim transaction, wherein the first healthcare claim transaction further comprises a prescriber identifier;

transmitting, by the service provider computer to the claims processor computer, the first healthcare claim transaction for adjudication;

determining, by the service provider computer and based at least in part on the prescriber identifier, if a stored record for the prescriber identified by the prescriber identifier comprises a prescriber facsimile number;

generating, by the service provider computer and based at least in part on the determination that the stored record does not comprise the prescriber facsimile number, a request for the prescriber facsimile number; and

appending, by the service provider computer, the request to the first adjudicated transaction response that is transmitted to the pharmacy computer.

10. The computer-implemented method of claim 9, wherein the second healthcare claim transaction further comprises the prescriber identifier and prescriber facsimile number and wherein the method further comprises:

retrieving, by the service provider computer, the prescriber facsimile number; and

electronically storing, by the service provider computer, the prescriber facsimile number in the stored record for the prescriber.

11. The computer-implemented method of claim 5, further comprising:

receiving, by the service provider computer from the pharmacy computer, the first healthcare claim transaction, wherein the first healthcare claim transaction further comprises a prescriber identifier;

determining, by the service provider computer and based at least in part on the prescriber identifier, if a stored record for the prescriber identified by the prescriber identifier comprises a prescriber facsimile number;

determining, by the service provider computer and based at least in part on the determination that the stored record does comprise the prescriber facsimile number, that the prescriber facsimile number needs to be validated;

generating, by the service provider computer and based at least in part on the determination that the stored prescriber facsimile number needs to be validated, a request for the prescriber facsimile number;

appending, by the service provider computer, the request to the first adjudicated transaction response that is transmitted to the pharmacy computer;

retrieving, by the service provider computer, the requested prescriber facsimile number from the second healthcare claim transaction;

comparing, by the service provider computer, the requested prescriber facsimile number to the stored facsimile number to determine if the requested facsimile number matches the stored facsimile number; and

electronically storing, by the service provider computer, the requested prescriber facsimile number in the stored record for the prescriber based at least on a positive determination that the requested prescriber facsimile number does not match the stored prescriber facsimile number.

12. The computer-implemented method of claim 5, wherein the method further comprises:

identifying, by the service provider computer, a first reject code in the first adjudicated transaction response; and

determining, by the service provider computer and based at least on the first reject code, that a basis for a rejection of the first healthcare claim transaction was for lack of prior authorization.

13. A system embodied by a switch or a router, the system comprising;

at least one memory operable to store computer-executable instructions and data files including a routing table and a record containing a time threshold limit;

a network interface; and

at least one processor configured to access the at least one memory and execute the computer-executable instructions to;

with reference to the routing table, determine a claims processor computer as a destination for a first healthcare claim transaction received from a pharmacy computer for a pharmacy and transmit the first healthcare claim transaction to the claims processor computer for adjudication;

receive, via the network interface from the claims processor computer, a first adjudicated transaction response for the first healthcare claim transaction comprising a first patient identifier for a patient;

a first transaction submission time, and first transaction comparison data;

in an instance in which the first healthcare claim transaction was rejected, store information relating to the first healthcare claim transaction in a rejected claims database in communication with the system;

modify, based at least in part on the first healthcare claim transaction being rejected for lack of prior authorization, the first adjudicated transaction response to include a prior authorization offer message;

direct communication, via the network interface to the pharmacy computer for the pharmacy, of the first adjudicated transaction response and the prior authorization offer message;

receive, via the network interface from the claims processor computer, a second adjudicated transaction response for a second healthcare claim transaction, the second healthcare claim transaction comprising a second patient identifier for the patient;

a second transaction submission time, and second transaction comparison data;

compare the second transaction comparison data to data in a plurality of records of previously processed healthcare transactions stored in the rejected claims database to identify a matching healthcare transaction record comprising matching transaction comparison data exists, wherein the matching healthcare transaction record comprises the first transaction submission time and the first transaction comparison data;

receive the second transaction submission time and the first transaction submission time;

calculate a submission time difference between the second transaction submission time and the first transaction submission time;

with reference to the record containing the time threshold limit stored by the data files, compare the submission time difference to the time limit threshold to determine if the submission time difference satisfies the time limit threshold;

determine, based at least in part on the positive determination that the submission time difference satisfies the time limit threshold, that the second healthcare claim transaction is a request for the prior authorization service; and

modify, based at least in part on the second healthcare claim transaction being rejected for lack of prior authorization, a second adjudicated transaction response to include a prior authorization assistance request acceptance message.

14. The system of claim 13, wherein the processor is further configured to access the at least one memory and execute the computer-executable instructions to:

determine, based at least on a reject code in the second adjudicated transaction response, that the second healthcare claim transaction was rejected for lack of prior authorization;

wherein comparing the second transaction comparison data to data in the plurality of records of previously processed healthcare transactions is completed based at least in part on the determination that the second healthcare claim transaction was rejected for lack of prior authorization.

15. The system of claim 13, wherein the second transaction comparison data comprises:

a product identifier identifying a product or service for the patient;

a payor identifier;

a prescription/service reference number;

a banking identification number, a processor control number, a fill number, a quantity dispensed, and a days'"'"' supply.

16. The system of claim 13, wherein the processor is further configured to access the at least one memory and execute the computer-executable instructions to:

direct communication, to the pharmacy computer, of the prior authorization assistance request acceptance message;

generate, based at least in part on the request for prior authorization assistance and one or more of the first and second healthcare claim transactions, a prior authorization assistance request; and

direct communication of the prior authorization assistance request to a prior authorization assistance computer.

17. The system of claim 13, wherein the processor is further configured to access the at least one memory and execute the computer-executable instructions to:

receive, from the pharmacy computer, the first healthcare claim transaction, wherein the first healthcare claim transaction further comprises a prescriber identifier;

determine, based at least in part on the prescriber identifier, if a stored record for the prescriber identified by the prescriber identifier comprises a prescriber facsimile number;

generate, based at least in part on the determination that the stored record does not comprise the prescriber facsimile number, a request for the prescriber facsimile number; and

append the request to the first adjudicated transaction response that is transmitted to the pharmacy computer.

18. The system of claim 17, wherein the second healthcare claim transaction further comprises the prescriber identifier and prescriber facsimile number and wherein the processor is further configured to access the at least one memory and execute the computer-executable instructions to:

receive the prescriber facsimile number; and

electronically store the prescriber facsimile number in the stored record for the prescriber.

19. The system of claim 13, wherein the processor is further configured to access the at least one memory and execute the computer-executable instructions to:

receive, from the pharmacy computer, the first healthcare claim transaction, wherein the first healthcare claim transaction further comprises a prescriber identifier;

determine, based at least in part on the prescriber identifier, if a stored record for the prescriber identified by the prescriber identifier comprises a prescriber facsimile number;

determine, based at least in part on the determination that the stored record does comprise the prescriber facsimile number, that the prescriber facsimile number needs to be validated;

generate, based at least in part on the determination that the stored prescriber facsimile number needs to be validated, a request for the prescriber facsimile number;

append the request to the first adjudicated transaction response that is transmitted to the pharmacy computer;

retrieve the requested prescriber facsimile number from the second healthcare claim transaction;

compare the requested prescriber facsimile number to the stored facsimile number to determine if the requested facsimile number matches the stored facsimile number; and

electronically store the requested prescriber facsimile number in the stored record for the prescriber based at least on a positive determination that the requested prescriber facsimile number does not match the stored prescriber facsimile number.

20. The system of claim 13, wherein the processor is further configured to access the at least one memory and execute the computer-executable instructions to:

identify a first reject code in the first adjudicated transaction response; and

determine, based at least on the first reject code, that a basis for a rejection of the first healthcare claim transaction was for lack of prior authorization.