Methods and systems for claim adjudication

• US 10,438,693 B1
• Filed: 12/28/2011
• Issued: 10/08/2019
• Est. Priority Date: 12/28/2011
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Inventors: Vandervoort, John William, Sundar, Heather D., Chen, Michael Z., Kautzner, Adam W., Canis, Randy L.
• Primary Examiner(s): Lam, Eliza A
• Application Number:
  US13/338,890
• Time in Patent Office: 2,841 Days
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/60 relating to nutrition control, e.g. diets
• 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

Methods and systems for claim adjudication are described. In one embodiment, a status of a drug benefit plan associated with a member is determined. Claims data associated with the member is accessed. A current-filled prescription is identified based on the claims data. At least one adjudication operation for the current-filled prescription is performed prior to receiving a new request for the current-filled prescription. The new request is determined as fillable based on the performance of the at least one adjudication operation. A notification is generated to the member based on the determination. Additional methods and systems are disclosed.

Claims

1. A method comprising:

determining, on a processor of an adjudication subsystem of a pharmacy benefit manager device, a status reflecting that a member, having a universal identifier, has changed from a drug benefit plan to a different drug benefit plan;

associating, on the processor of the adjudication subsystem of the pharmacy benefit manager device, the different drug benefit plan with the universal identifier;

accessing, on the processor of the pharmacy benefit manager device, first claims data associated with the drug benefit plan based on the universal identifier associated with the member from a database via a network;

determining, on the processor of the pharmacy benefit manager device, that second claims data is also associated with the universal identifier;

accessing, on the processor of the pharmacy benefit manager device, the second claims data associated with the different drug benefit plan based on the universal identifier associated with the member from the database via the network;

analyzing, on the processor of the pharmacy benefit manager device, the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan;

combining, on the processor of the pharmacy benefit manager device, the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan in response to analysis of the first claims data and the second claims data to generate a claims history of the member;

identifying, on the processor of the pharmacy benefit manager device, a current-filled prescription based on the first claims data from the drug benefit plan accessed using the universal identifier and the second claims data from the different drug benefit plan accessed using the universal identifier;

performing, on the processor of the pharmacy benefit manager device, at least one adjudication operation for the current-filled prescription prior to receiving a new request for the current-filled prescription from a pharmacy device via a network, wherein performing the at least one adjudication operation for the current-filled prescription comprises determining a co-pay, coinsurance, and deductible for the current-filled prescription at each of one or more pharmacies capable of fulfilling the current-filled prescription;

prior to receipt of the new request for the current-filled prescription, determining, on the processor of the pharmacy benefit manager device, whether the new request is fillable subsequent to and based on performance of the at least one adjudication operation;

generating, on the processor of the pharmacy benefit manager device, a notification to the member based on a result of a determination of whether the new request is fillable;

transmitting the notification from a network interface device of the pharmacy benefit manager device to a member device of the member via the network; and

dispensing the current-filled prescription at a pharmacy of the one or more pharmacies capable of fulfilling the current-filled prescription when the new request is fillable.

2. The method of claim 1, wherein the first claims data includes data indicating eligibility for a prescription drug, access to the prescription drug, access to supporting information associated with the prescription drug, data associated with a provider of the prescription drug, demographic information associated with the member, data associated with the pharmacy dispensing the prescription drug, or any combination thereof.

3. The method of claim 1, further comprising:

generating the claims history of the member based on the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan; and

performing the at least one adjudication operation based on the generated claims history of the member.

4. The method of claim 3, wherein the different drug benefit plan is related to at least one of a current job, a supplemental benefit, or both, the drug benefit plan being related to a prior job, wherein the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan are linked by the universal identifier;

wherein combining the first claims data and the second claims data includes;

determining a first-fill date for a prescription drug associated with the universal identifier from both the drug benefit plan and the different drug benefit plan, and

identifying potential interactions between a first drug filled under the drug benefit plan and a second drug filled under the different drug benefit plan.

5. The method of claim 1, further comprising:

receiving a prescription drug history of the member from the member; and

performing the at least one adjudication operation based on receipt of the prescription drug history of the member.

6. The method of claim 1, wherein performing the at least one adjudication operation for the current-filled prescription further comprises:

determining a price of the current-filled prescription at each of one or more pharmacies capable of fulfilling the current-filled prescription; and

transmitting to the member the price of the current-filled prescription at each of the one or more pharmacies capable of fulfilling the current-filled prescription.

12. The method of claim 1, wherein the status reflects that the member has changed from the drug benefit plan to the different drug benefit plan since previously receiving a prescription drug fill of the current-filled prescription, the prescription drug fill being adjudicated under the drug benefit plan.

13. The method of claim 1, wherein the status reflects an acknowledged willingness that the member has changed from the drug benefit plan to the different drug benefit plan since previously receiving a prescription drug fill of the current-filled prescription, the prescription drug fill being adjudicated under the drug benefit plan.

14. The method of claim 1, wherein the at least one adjudication operation includes determining coverage of the current-filled prescription under the drug benefit plan.

15. The method of claim 1, wherein the notification reflects that the current-filled prescription is not fillable under the different drug benefit plan.

16. The method of claim 1, wherein the determination of the status reflects that the member has changed from the drug benefit plan to the different drug benefit plan, the current-filled prescription being associated with the drug benefit plan, and

wherein performance of the at least one adjudication operation is based on a determination that the status that the member has changed from the drug benefit plan to the different drug benefit plan.

17. The method of claim 1, wherein the status is a drug benefit enrollment status reflecting drug benefit plan enrollment, change of the drug benefit enrollment status reflecting member changes of drug benefit plan enrollment from the drug benefit plan to the different drug benefit plan.

18. The method of claim 1, wherein the determination of the status reflects that the member will change from the drug benefit plan to the different drug benefit plan, the current-filled prescription being associated with the drug benefit plan, and

wherein performance of the at least one adjudication operation is based on a determination that the status of the member will change from the drug benefit plan to the different drug benefit plan.

19. The method of claim 1, wherein performing the at least one adjudication operation includes determining that the new request for the current-filled prescription requires a prior authorization, and wherein a determination of whether the new request is fillable subsequent to and based on performance of the at least one adjudication operation includes determining that the current-filled prescription did not require a prior authorization, and the notification reflects that the member needs to obtain a prior authorization in conjunction with receiving the new request for the current-filled prescription.

7. A non-transitory machine-readable medium comprising instructions, which when executed by one or more processors, cause the one or more processors to perform the following operations:

determine a status reflecting that a member, having a universal identifier, has changed from a drug benefit plan to a different drug benefit plan;

associate the different drug benefit plan with the universal identifier;

access first claims data associated with drug benefit plan based on the universal identifier associated with the member from a database via a network;

determine that second claims data is also associated with the universal identifier;

access the second claims data associated with the different drug benefit plan based on the universal identifier associated with the member from the database via the network;

analyze the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan;

combine the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan in response to analysis of the first claims data and the second claims data to generate a claims history of the member;

identify a current-filled prescription based on the first claims data accessed using the universal identifier from the drug benefit plan and the second claims data from the different drug benefit plan accessed using the universal identifier;

perform at least one adjudication operation for the current-filled prescription prior to receiving a new request for the current-filled prescription from a pharmacy device via a network, wherein instructions to perform the at least one adjudication operation for the current-filled prescription comprise instructions to determine a co-pay, coinsurance, and deductible for the current-filled prescription at each of one or more pharmacies capable of fulfilling the prescription;

prior to receipt of the new request for the current-filled prescription, determine whether the new request is fillable based on performance of the at least one adjudication operation for the current-filled prescription;

generate a notification to the member based on a result of a determination of whether the new request is fillable;

transmit the notification to a member device of the member via the network; and

cause the current-filled prescription to be dispensed at a pharmacy of the one or more pharmacies capable of fulfilling the current-filled prescription when the new request is fillable.

8. The non-transitory machine-readable medium of claim 7, wherein the first claims data includes data indicating eligibility for a prescription drug, access to the prescription drug, access to supporting information associated with the prescription drug, data associated with a provider of the prescription drug, demographic information associated with the member, data associated with the pharmacy dispensing the prescription drug, or any combination thereof.

9. The non-transitory machine-readable medium of claim 7, further comprises instructions to:

receive a prescription drug history of the member from the member; and

perform the at least one adjudication operation based on the received prescription drug history of the member.

10. The non-transitory machine-readable medium of claim 7, wherein instructions to perform the at least one adjudication operation for the current-filled prescription comprise instructions to:

determine a price of the current-filled prescription at each of one or more pharmacies capable of fulfilling the current-filled prescription; and

transmit the price of the current-filled prescription at each of the one or more pharmacies capable of fulfilling the prescription.

11. A system comprising:

a processor and a memory coupled to the processor;

a drug benefit plan module deployed in the memory and executed by the processor of an adjudication subsystem of a pharmacy benefit manager device to determine a status reflecting that a member, having a universal identifier, has changed from a drug benefit plan to a different drug benefit plan and associate the different drug benefit plan with the universal identifier;

a claims data module deployed in the memory and executed by the processor of the pharmacy benefit manager device to access first claims data associated with the drug benefit plan based on the universal identifier associated with the member from a database via a network, determine that second claims data is also associated with the universal identifier, access the second claims data associated with the different drug benefit plan based on the universal identifier associated with the member from the database via the network, analyze the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan, combine the first claims data from the drug benefit plan and the second claims data from the different drug benefit plan in response to analysis of the first claims data and the second claims data to generate a claims history of the member;

a prescription module deployed in the memory and executed by the processor of the pharmacy benefit manager device to identify a current-filled prescription based on the first claims data accessed using the universal identifier from the drug benefit plan and the second claims data from the different drug benefit plan accessed using the universal identifier;

an adjudication module deployed in the memory and executed by the processor of the pharmacy benefit manager device to perform at least one adjudication operation for the current-filled prescription prior to receiving a new request for the current-filled prescription from a pharmacy device via a network, wherein the adjudication module performing the at least one adjudication operation comprises that adjudication module determining a co-pay, coinsurance, and deductible for the current-filled prescription at each of one or more pharmacies capable of fulfilling the prescription;

a coverage check module deployed in the memory and executed by the processor of the pharmacy benefit manager device to determine, prior to receipt of the new request for the current-filled prescription, that the new request is fillable based on performance of the at least one adjudication operation, and cause the current-filled prescription to be dispensed at a pharmacy of the one or more pharmacies capable of fulfilling the current-filled prescription when the new request is fillable;

a notification module deployed in the memory and executed by the processor of the pharmacy benefit manager device to generate a notification to the member based on a result of a determination of whether the new request is fillable; and

a network interface device of the pharmacy benefit manager device in communication with a network to transmit the notification to a member device of the member via the network.