Systems and methods for identifying prior authorization assistance requests in healthcare transactions
First Claim
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.
4 Assignments
0 Petitions
Accused Products
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.
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Citations
20 Claims
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1. A computer-implemented method, comprising:
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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. - View Dependent Claims (2, 3, 4)
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5. A computer-implemented method, comprising:
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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. - View Dependent Claims (6, 7, 8, 9, 10, 11, 12)
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13. A system embodied by a switch or a router, the system comprising;
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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. - View Dependent Claims (14, 15, 16, 17, 18, 19, 20)
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Specification