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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
First Claim
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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.

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