Systems and methods for determining and communicating information to a pharmacy indicating patient eligibility for an intervention service

• US 10,430,555 B1
• Filed: 03/13/2014
• Issued: 10/01/2019
• Est. Priority Date: 03/13/2014
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: McKesson Corp.
• Inventors: Pinsonneault, Sr., Roger G., Burgett, Scott
• Primary Examiner(s): Gort, Elaine
• Assistant Examiner(s): Reichert, Rachelle L
• Application Number:
  US14/209,248
• Time in Patent Office: 2,028 Days
• Field of Search: None
• 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

Systems and methods are provided for determining and communicating intervention service opportunities, such as medication therapy management services, that may be available for a patient, as part of processing a healthcare claim transaction. A healthcare claim transaction, such as a prescription benefit request transaction, may be received by the service provider computer from a healthcare provider computer. The service provider computer may determine if an intervention service is available for the patient and if an available intervention service notification has been transmitted to the pharmacy computer prior to the service provider computer receiving the healthcare claim transaction. The service provider computer may receive an approved adjudicated response and generate a patient intervention service form corresponding to the available intervention service for the patient. The service provider computer may transmit the patient intervention service form to the pharmacy computer and receive a completed patient intervention service form from the pharmacy computer.

Claims

1. A computer-implemented method, comprising:

receiving, by one or more service provider computers comprising a switch or a router and associated with a service provider, a first prescription claim transaction for a prescribed product prescribed to a patient and to be filled by a pharmacy, the first prescription claim transaction comprising a prescription number, a product identifier for the prescribed product, a patient identifier for the patient prescribed the prescribed product, a pharmacy identifier, and a claims processor identifier;

determining, by the one or more service provider computers and based at least on the patient identifier in the first prescription claim transaction, at least one intervention service is available for the patient;

determining, by the one or more service provider computers and after receipt of the first prescription claim transaction, if an available intervention service notification associated with the at least one available intervention service was previously transmitted to a pharmacy computer for the patient at a time prior to receiving the first prescription claim transaction, wherein determining if an available intervention service notification was previously transmitted comprises parsing intervention notification files stored in a database to determine if the patient identifier matches a patient identifier in the intervention notification files, and in response to the patient identifier matching a patient identifier in the intervention notification files, determine if the intervention notification files include a file having the matching patient identifier corresponding to the available intervention service;

generating, by the one or more service provider computers and based on a determination that the available intervention service notification has not been previously transmitted, a rejection response for the prescription claim transaction;

transmitting, by the one or more service provider computers to the pharmacy computer, the rejection response, the response comprising the available intervention service notification, wherein the one or more service provider computers comprises one or more memory devices configured to store data files that include a routing table to identify a destination of communications and a network interface to facilitate connection of the one or more service provider computers with one or more networks;

generating, by the one or more service provider computers, a patient intervention service form corresponding to the at least one available intervention service for the patient, wherein generation of the patient intervention service form comprises;

retrieving, from a storage database, a patient intervention service template comprising standardized information to be applied to each of a plurality of intervention types; and

populating, by the one or more service provider computers, the patient intervention service template based on an intervention type associated with the available intervention service and with patient information included in the first prescription claim transaction, the populated information comprising at least the prescription number, the patient name, and the pharmacy identifier, wherein the generated patient intervention service form comprises at least one element requiring patient input for completion;

transmitting, by the one or more service provider computers and separate from the rejection response, the patient intervention service form corresponding to the at least one available intervention service for the patient to the pharmacy computer to facilitate provision of an indication of availability of the patient intervention form to a pharmacist in response to receiving a request for the prescription from the patient or an associated patient caregiver in order to permit completion of the patient intervention service form by the pharmacist; and

receiving, by the one or more service provider computers from the pharmacy computer, a completed patient intervention service form corresponding to the transmitted patient intervention service form, wherein the completed patient intervention service form comprises at least one element completed with patient input.

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

determining, by the one or more service provider computers and after receipt of the first prescription claim transaction, that the available intervention service notification associated with the at least one available intervention service has previously been transmitted to the pharmacy computer at the time prior to receiving the first prescription claim transaction;

transmitting, by the one or more service provider computers and in response to a positive determination that the at least one available intervention service has previously been transmitted to the pharmacy computer at the time prior to receiving the first prescription claim transaction, the first prescription claim transaction to a claims processor computer for adjudication; and

receiving, by the one or more service provider computers from the claims processor computer, an approved adjudicated healthcare claim transaction response for the first prescription claim transaction.

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

transmitting, by the one or more service provider computers to the pharmacy computer, the adjudicated prescription claim transaction response.

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

receiving, by the one or more service provider computers, a plurality of intervention service forms comprising at least the completed patient service form;

determining, by the one or more service provider computers, that an available intervention services reporting period has closed; and

generating, by the one or more service provider computers, an available intervention services report comprising patient information collected from the plurality of intervention service forms.

5. The computer-implemented method of claim 1, wherein determining that at least one intervention service is available for the patient identified in the first prescription claim transaction comprises one or more of:

(i) determining whether the product identifier identifies an eligible product, (ii) determining whether the pharmacy identifier identifies an eligible pharmacy, or (iii) determining whether a benefits provider identifier identifies an eligible claims processor.

6. The computer-implemented method of claim 1, further comprising accessing, by the one or more service provider computers, a patient intervention service file corresponding to the patient identifier in the first prescription claim transaction, wherein the patient intervention service file comprises one or more intervention service types available to the patient identified in the first prescription claim transaction.

7. The computer-implemented method of claim 1, wherein the completed patient intervention service form comprises at least a patient signature and a date associated with the patient signature.

8. The computer-implemented method of claim 1, wherein the at least one available intervention service for the patient is a medication therapy management service.

17. The computer-implemented method of claim 1, further comprising transmitting, by the one or more service provider computers and to a sponsor computer for a sponsor of the at least one intervention service, a notification that the at least one intervention service has been completed for the patient, wherein the notification comprises at least a portion of data in the completed patient intervention service form.

19. The computer-implemented method of claim 1, wherein the patient intervention service form is provided to the pharmacy computer for printing and presentation to the patient.

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

correlating the received completed patient intervention form with the previously stored patient intervention service form;

capturing and facilitating storage of data in the completed patient intervention form; and

providing a notification that the patient intervention form was properly completed.

9. A system comprising a switch or a router, the system comprising:

at least one memory operable to store computer-executable instructions and configured to store data files that include a routing table to identify a destination of communications;

a network interface to facilitate connection with one or more networks; and

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

receive, from a pharmacy computer for a pharmacy, a first prescription claim transaction for a prescribed product prescribed to a patient and to be filled by the pharmacy, the first prescription claim transaction comprising a prescription number, a product identifier for the prescribed product, a patient identifier for the patient prescribed the prescribed product, a pharmacy identifier, and a claims processor identifier;

determine, based at least on the patient identifier in the first prescription claim transaction, that at least one intervention service is available for the patient;

determine, after receipt of the first prescription claim transaction, if an available intervention service notification associated with the at least one available intervention service was previously transmitted to a pharmacy computer for the patient at a time prior to receiving the first prescription claim transaction wherein the computer executable instructions to determine if an available intervention service notification was previously transmitted comprises computer executable instructions to parse intervention notification files to determine if the patient identifier matches a patient identifier in the intervention notification files, and in response to the patient identifier matching a patient identifier in the intervention notification files, determine if the intervention notification files include a file having the matching patient identifier corresponding to the available intervention service;

generate, based on a determination that the available intervention service notification has not been previously transmitted, a rejection response for the prescription claim transaction;

transmit the rejection response to the pharmacy computer based on the stored routing table, the rejection response comprising the available intervention service notification;

generate a patient intervention service form corresponding to the at least one available intervention service for the patient, wherein generation of the patient intervention service form comprises;

computer executable instructions to retrieve, from a storage database, a template comprising standardized information to be applied to each of a plurality of intervention types; and

computer executable instructions to populate, by the one or more service provider computers, the patient intervention service template based on an intervention type associated with the available intervention service and with patient information included in the first prescription claim transaction, the populated information comprising at least the prescription number, the patient name, and the pharmacy identifier, wherein the generated patient intervention service form comprises at least one element requiring patient input for completion;

transmit, separate from the rejection response, the patient intervention service form corresponding to the at least one available intervention service for the patient to the pharmacy computer to facilitate provision of an indication of availability of the patient intervention form to a pharmacist in response to receiving a request for the prescription from the patient or an associated patient caregiver in order to permit completion of the patient intervention service form by the pharmacist; and

receive, a completed patient intervention service form corresponding to the transmitted patient intervention service form.

10. The system of claim 9, wherein the at least one processor is further configured to execute the computer-executable instructions to:

determine, after receipt of the first prescription claim transaction, that the available intervention service notification associated with the at least one available intervention service has previously been transmitted to the pharmacy computer at the time prior to receiving the first prescription claim transaction;

transmit, in response to a positive determination that the at least one available intervention service has previously been transmitted to the pharmacy computer at the time prior to receiving the first prescription claim transaction, the first prescription claim transaction to a claims processor computer of a claims processor for adjudication; and

receive an approved adjudicated prescription claim transaction response for the first prescription claim transaction.

11. The system of claim 10, wherein the at least one processor is further configured to execute the computer-executable instructions to transmit the adjudicated prescription claim transaction response to the pharmacy computer.

12. The system of claim 9, wherein the at least one processor is further configured to execute the computer-executable instructions to:

receive a plurality of intervention service forms comprising at least the completed patient service form;

determine that an available intervention services reporting period has closed; and

generate an available intervention services report comprising patient information collected from the plurality of intervention service forms.

13. The system of claim 9, wherein the at least one processor is further configured to execute the computer-executable instructions to determine that at least one service is available for the patient identified in the first prescription claim transaction comprises one or more of:

(i) determining whether the product identifier identifies an eligible product, (ii) determining whether the pharmacy identifier identifies an eligible pharmacy, or (iii) determining whether a benefits provider identifier identifies an eligible claims processor.

14. The system of claim 9, wherein the at least one processor is further configured to execute the computer-executable instructions to access a patient intervention service file corresponding to the patient identifier in the first prescription claim transaction, wherein the patient intervention service file comprises one or more intervention service types available to the patient identified in the first prescription claim transaction.

15. The system of claim 9, wherein,

the completed patient intervention service form comprises at least a patient signature and a date associated with the patient signature, and

wherein the at least one processor is further configured to execute the computer-executable instructions to receive the completed patient intervention service form from the pharmacy computer via a facsimile.

16. The system of claim 9, wherein the at least one available intervention service for the patient is a medication therapy management service.

18. The system of claim 9, wherein the at least one processor is further configured to execute the computer-executable instructions to transmit, to a sponsor computer for a sponsor of the at least one intervention service, a notification that the at least one intervention service has been completed for the patient, wherein the notification comprises at least a portion of data in the completed patient intervention service form.