Systems and methods for determining, collecting, and configuring patient intervention screening information from a pharmacy

• US 10,642,957 B1
• Filed: 10/21/2014
• Issued: 05/05/2020
• Est. Priority Date: 10/21/2014
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: McKesson Corp.
• Inventors: Pinsonneault, Roger G., Crockett, Kristina
• Primary Examiner(s): Nguyen, Hiep V
• Application Number:
  US14/519,626
• Time in Patent Office: 2,023 Days
• Field of Search: 705 2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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

A healthcare claim transaction may be received by a service provider computer from a pharmacy computer. An intervention service for a patient may be identified and the screening parameters to be obtained from the patient for the intervention service may be identified. The service provider computer may generate a reject response and insert a reject code and/or message notifying the pharmacy of the first screening parameter to obtain from the patient. The rejection response may be sent to the pharmacy computer, which may subsequently send a resubmitted healthcare claim transaction that includes the requested first screening parameter data for the patient. The service provider computer may parse the transaction to identify the data. The iterative process may continue until all of the screening parameter data for the patient is received by the service provider computer, which may transmit that data to a claims processor computer.

Claims

1. A computer-implemented method for determining patient intervention services, the method comprising:

receiving, by one or more service provider computers comprising one or more processors from a pharmacy computer associated with a pharmacy, a healthcare claim transaction comprising a patient identifier identifying a patient and a destination identifier;

in response to receipt of the healthcare claim transaction, determining whether (1) an intervention service is available for the patient identified by the patient identifier based upon a review of patient eligibility information from a patient eligibility file accessible by the one or more service provider computers, (2) the intervention service is contracted for by a claims processor computer identified by the destination identifier based upon a review of claims processor eligibility information from a eligible claims processor file accessible by the one or more service provider computers and (3) the pharmacy that provided the healthcare claim transaction has contracted to receive intervention service notifications based upon a review of pharmacy eligibility information from a pharmacy eligibility file accessible by the one or more service provider computers, wherein the intervention service comprises at least one of wellness screening, blood pressure monitoring, medication therapy management services, immunization messaging, cash prescription monitoring, refill adherence, high-risk medication monitoring or diabetic screening or monitoring;

in an instance in which a determination is made that the intervention service is available for the patient, the intervention service is contracted for by the claims processor computer and the pharmacy has contracted to receive intervention service notifications, identifying, by the one or more service provider computers from an intervention parameter file and based at least in part on the destination identifier, a plurality of screening parameters for the intervention service available to the patient identified by the patient identifier;

wherein for each of the plurality of screening parameters, the method further comprises;

a. identifying, by the one or more service provider computers, a first screening parameter of the plurality of screening parameters for the intervention service, wherein the first screening parameter is identified by a counter variable that is set equal to 1;

b. identifying, by the one or more service provider computers, at least one of a reject code or a reject message providing a notification of the first screening parameter;

c. generating, by the one or more service provider computers, a reject response to the healthcare claim transaction;

d. inserting, by the one or more service provider computers, the identified at least one reject code or reject message providing a notification of the first screening parameter for the intervention service into the reject response to the healthcare claim transaction;

e. transmitting, by the one or more service provider computers, the reject response to the healthcare claim transaction to the pharmacy computer, wherein the reject response to the healthcare claim transaction is transmitted prior to adjudication of the healthcare claim transaction by a claims processor computer and includes an indication that the healthcare claim transaction should be resubmitted;

f. receiving, by the one or more service provider computers, a resubmitted healthcare claim transaction from the pharmacy computer, the resubmitted healthcare claim transaction comprising a pharmacy identifier identifying the pharmacy associated with the pharmacy computer, the patient identifier for the patient, and the destination identifier;

g. determining, by the one or more service provider computers, if the resubmitted healthcare claim transaction includes a first patient parameter data for the first screening parameter for the intervention service;

h. identifying, by the one or more service provider computers and based at least on the positive determination that the resubmitted healthcare claim transaction includes the first patient parameter data for the first screening parameter, the first patient parameter data for the first screening parameter; and

i. repeating, by the one or more service provider computers, steps (a)-(h) for each of the plurality of screening parameters for the intervention service to receive a plurality of patient parameter data corresponding to the plurality of screening parameters for the intervention service, wherein repeating steps (a)-(h) comprises evaluating, by the one or more service provider computers and based at least in part on the destination identifier of the resubmitted healthcare claim transaction identifying the intervention service to be provided, the plurality of screening parameters from the intervention parameter file that are to be requested; and

in an instance in which at least one screening parameter remains to be requested, incrementing the counter variable that designates the screening parameter to be requested prior to repeating steps (a)-(h); and

transmitting, by the one or more service provider computers, the received plurality of patient parameter data for the intervention service to the claims processor computer associated with a claims processor, wherein transmitting comprises routing the plurality of patient parameter data for the intervention service to the claims processor computer in accordance with a routing table associated with the one or more service provider computers.

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

comprising:

receiving, by the one or more service provider computers from the pharmacy computer, a prior healthcare claim transaction comprising a product identifier for a prescribed product and a patient identifier identifying a patient to receive the prescribed product, wherein the prior healthcare transaction is received by the one or more service provider computers prior to the healthcare claim transaction;

determining, by the one or more service provider computers and based at least in part on the patient identifier, at least one intervention service available for the patient identified in the prior healthcare claim transaction;

generating, by the one or more service provider computers, a prior reject response to the prior healthcare claim transaction, wherein the prior reject response comprises an indicator of the intervention service available for the patient; and

transmitting, by the one or more service provider computers, the prior reject response to the pharmacy computer.

3. The computer-implemented method of claim 1, wherein

identifying the plurality of screening parameters for the intervention service comprises:

comparing, by the one or more service provider computers, the destination identifier to at least one intervention service destination identifier that identifies at least one intervention service to determine if a match exists;

determining, by the one or more service provider computers and based at least in part on the comparison of the destination identifier to the at least one intervention service destination identifier, that the healthcare claim transaction is for the intervention service available to the patient; and

identifying, by the one or more service provider computers and based at least in part on the determination that the healthcare claim transaction is for the intervention service available to the patient, the plurality of screening parameters for data to obtain from the patient in the intervention service.

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

f. 1. determining, by the one or more service provider computers and based at least in part on the pharmacy identifier and the patient identifier, that the pharmacy is conducting the intervention service for the patient.

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

g. 1. parsing, by the one or more service provider computers and based at least on the negative determination that the resubmitted healthcare claim transaction includes the first patient parameter data for the first screening parameter, the resubmitted healthcare claim transaction to identify a reason code, wherein the reason code designates a reason that the first patient parameter data was not included in the resubmitted healthcare claim transaction;

g.2 storing, by the one or more service provider computers, the identified reason code; and

g.3 modifying, by the one or more service provider computers, the resubmitted healthcare claim transaction by removing the identified reason code from the resubmitted healthcare claim transaction.

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

g.4. transmitting the modified resubmitted healthcare claim transaction to a second claims processor computer for adjudication.

7. The computer-implemented method of claim 1, wherein the intervention service is a wellness screening intervention service for the patient and wherein the plurality of screening parameters for the wellness screening intervention service comprise at least two or more of:

patient blood pressure, patient total cholesterol measurement, patient high-density lipoproteins cholesterol measurement, patient low-density lipoproteins cholesterol measurement, patient triglycerides measurement, patient blood glucose measurement, patient height, patient weight, and patient waist measurement.

8. The computer-implemented method of claim 1, wherein transmitting the received plurality of patient parameter data for the intervention service to a claims processor computer comprises:

generating, by the one or more service provider computers, a single healthcare claim transaction;

inserting, by the one or more service provider computers, each of the plurality of patient parameter data into the single healthcare claim transaction; and

transmitting, by the one or more service provider computers, the single healthcare claim transaction to the claims processor computer.

9. A system for determining patient intervention services, the system comprising:

at least one memory operable to store computer-executable instructions; 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 associated with a pharmacy, a healthcare claim transaction comprising a patient identifier identifying a patient and a destination identifier;

in response to receipt of the healthcare claim transaction, determine whether (1) an intervention service is available for the patient identified by the patient identifier based upon a review of patient eligibility information from a patient eligibility file accessible by the system, (2) the intervention service is contracted for by a claims processor computer identified by the destination identifier based upon a review of claims processor eligibility information from a eligible claims processor file accessible by the one or more service provider computers and (3) the pharmacy that provided the healthcare claim transaction has contracted to receive intervention service notifications based upon a review of pharmacy eligibility information from a pharmacy eligibility file accessible by the one or more service provider computers, wherein the intervention service comprises at least one of wellness screening, blood pressure monitoring, medication therapy management services, immunization messaging, cash prescription monitoring, refill adherence, high-risk medication monitoring or diabetic screening or monitoring;

in an instance in which a determination is made that the intervention service is available for the patient, the intervention service is contracted for by the claims processor computer and the pharmacy has contracted to receive intervention service notifications, identify, from an intervention parameter file, screening parameters for the intervention service available to the patient identified by the patient identifier;

wherein for each of the plurality of screening parameters, the at least one processor is further configured to access the at least one memory and execute the computer-executable instructions to;

a. identify a first screening parameter of the plurality of screening parameters for the intervention service, wherein the first screening parameter is identified by a counter variable that is set equal to 1;

b. identify, based on the first screening parameter, at least one of a reject code or a reject message providing a notification of the first screening parameter;

c. generate a reject response to the healthcare claim transaction;

d. insert the identified at least one reject code or reject message providing a notification of the first screening parameter for the intervention service into the reject response to the healthcare claim transaction;

e. direct communication of the reject response to the healthcare claim transaction to the pharmacy computer, wherein the reject response to the healthcare claim transaction is communicated prior to adjudication of the healthcare claim transaction by a claims processor computer and includes an indication that the healthcare claim transaction should be resubmitted;

f. receive a resubmitted healthcare claim transaction from the pharmacy computer, the resubmitted healthcare claim transaction comprising a pharmacy identifier identifying the pharmacy associated with the pharmacy computer, the patient identifier for the patient, and the destination identifier;

g. determine if the resubmitted healthcare claim transaction includes a first patient parameter data for the first screening parameter for the intervention service;

h. identify, based at least on the positive determination that the resubmitted healthcare claim transaction includes the first patient parameter data for the first screening parameter, the first patient parameter data for the first screening parameter; and

i. repeat steps (a)-(h) for each of the plurality of screening parameters for the intervention service to receive a plurality of patient parameter data corresponding to the plurality of screening parameters for the intervention service, wherein repeating steps (a)-(h) comprises evaluating, based at least in part on the destination identifier of the resubmitted healthcare claim transaction identifying the intervention service to be provided, the plurality of screening parameters from the intervention parameter file that are to be requested; and

in an instance in which at least one screening parameter remains to be requested, incrementing the counter variable that designates the screening parameter to be requested prior to repeating steps (a)-(h); and

direct communication of the received plurality of patient parameter data for the intervention service to the claims processor computer associated with a claims processor, wherein transmitting comprises routing the plurality of patient parameter data for the intervention service to the claims processor computer in accordance with a routing table associated with the system.

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

receive, from the pharmacy computer, a prior healthcare claim transaction comprising a product identifier for a prescribed product and the patient identifier identifying the patient to receive the prescribed product, wherein the prior healthcare transaction is received by the one or more service provider computers prior to the healthcare claim transaction;

determine, based at least in part on the patient identifier, at least one intervention service available for the patient identified in the prior healthcare claim transaction;

generate a prior reject response to the prior healthcare claim transaction, wherein the prior reject response comprises an indicator of the intervention service available for the patient; and

direct communication of the prior reject response to the pharmacy computer.

11. The system of claim 9, wherein the at least one processor is configured to identify the plurality of screening parameters for the intervention service by accessing the at least one memory and executing the computer-executable instructions to:

compare the destination identifier to at least one intervention service destination identifier that identifies at least one intervention service to determine if a match exists;

determine, based at least in part on the comparison of the destination identifier to the at least one intervention service destination identifier, that the healthcare claim transaction is for the intervention service available to the patient; and

identify, based at least in part on the determination that the healthcare claim transaction is for the intervention service available to the patient, the plurality of screening parameters for data to obtain from the patient in the intervention service.

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

f. 1. determine, based at least in part on the pharmacy identifier and the patient identifier, that the pharmacy is conducting the intervention service for the patient.

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

g. 1. parse, based at least on the negative determination that the resubmitted healthcare claim transaction includes the first patient parameter data for the first screening parameter, the resubmitted healthcare claim transaction to identify a reason code, wherein the reason code designates a reason that the first patient parameter data was not included in the resubmitted healthcare claim transaction;

g.2 store the identified reason code in the at least one memory; and

g.3 modify the resubmitted healthcare claim transaction by removing the identified reason code from the resubmitted healthcare claim transaction.

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

g.4. direct communication of the modified resubmitted healthcare claim transaction to a second claims processor computer for adjudication.

15. The system of claim 9, wherein the intervention service is a wellness screening intervention service for the patient and wherein the plurality of screening parameters for the wellness screening intervention service comprise at least two or more of:

patient blood pressure, patient total cholesterol measurement, patient high-density lipoproteins cholesterol measurement, patient low-density lipoproteins cholesterol measurement, patient triglycerides measurement, patient blood glucose measurement, patient height, patient weight, and patient waist measurement.

16. The system of claim 9, wherein the at least one processor is configured to direct communication of the received plurality of patient parameter data for the intervention service to the claims processor computer by accessing the at least one memory and executing the computer-executable instructions to:

generate a single healthcare claim transaction;

insert each of the plurality of patient parameter data into the single healthcare claim transaction; and

direct communication of the single healthcare claim transaction to the claims processor computer.

17. A computer-implemented method for determining patient intervention services, the method comprising:

receiving, by one or more service provider computers comprising one or more processors from a pharmacy computer associated with a pharmacy, a healthcare claim transaction comprising first data comprising a first prescription number, a first fill number, a first pharmacy identifier, a first date of service, a first product identifier for a prescribed product, a first patient identifier identifying a patient to receive the prescribed product and a destination identifier;

in response to receipt of the healthcare claim transaction, determining, by the one or more service provider computers, whether (1) at least one intervention service is available for the patient identified by the first patient identifier in the healthcare claim transaction based upon a review of patient eligibility information from a patient eligibility file accessible by the one or more service provider computers, (2) the intervention service is contracted for by a claims processor computer identified by the destination identifier based upon a review of claims processor eligibility information from a eligible claims processor file accessible by the one or more service provider computers and (3) the pharmacy that provided the healthcare claim transaction has contracted to receive intervention service notifications based upon a review of pharmacy eligibility information from a pharmacy eligibility file accessible by the one or more service provider computers, wherein the intervention service available for the patient comprises at least one of wellness screening, blood pressure monitoring, medication therapy management services, immunization messaging, cash prescription monitoring, refill adherence, high-risk medication monitoring or diabetic screening or monitoring;

in an instance in which a determination is made that the intervention service is available for the patient, the intervention service is contracted for by the claims processor computer and the pharmacy has contracted to receive intervention service notifications, generating, by the one or more service provider computers, a reject response to the healthcare claim transaction, wherein the reject response comprises an indicator of the intervention service available for the patient, and wherein an intervention parameter file identifies a plurality of screening parameters for the intervention service;

transmitting, by the one or more service provider computers, the reject response to the pharmacy computer, wherein the reject response to the healthcare claim transaction is transmitted prior to adjudication of the healthcare claim transaction by the claims processor computer and includes an indication that the healthcare claim transaction should be resubmitted;

receiving, by the one or more service provider computers from the pharmacy computer, a resubmitted healthcare claim transaction comprising second data comprising a second prescription number, a second fill number, a second pharmacy identifier, a second date of service, and the patient identifier identifying the patient;

comparing, by the one or more service provider computers, at least a portion of the first data to at least a portion of the second data to determine if a match exists between the portion of the first data and the portion of the second data;

in an instance in which the healthcare claim transaction is for an intervention service available to the patient and in which the resubmitted healthcare claim transaction includes a screening parameter for the intervention service, repeating, by the one or more service provider computers, the steps of generating the reject response, transmitting the reject response, receiving another resubmitted healthcare claim transaction including other data and another screening parameter for the intervention service and comparing at least a portion of the first data to a least a portion of the other data to determine if a match exists, wherein repeating the steps comprises evaluating, by the one or more service provider computers, the plurality of screening parameters from the intervention parameter file that are to be requested; and

in an instance in which at least one screening parameter remains to be requested, incrementing a counter variable that designates the screening parameter to be requested prior to repeating the steps;

otherwise, determining, by the one or more service provider computers and based at least in part on the comparison, that the healthcare claim transaction is not for an intervention service available to the patient;

parsing, by the one or more service provider computers and based at least on the determination that the resubmitted healthcare claim transaction is not for an intervention service available to the patient, the resubmitted healthcare claim transaction to identify a reason code, wherein the reason code designates a reason that the intervention service available to the patient was not completed;

storing, by the one or more service provider computers, the identified reason code;

modifying, by the one or more service provider computers, the resubmitted healthcare claim transaction by removing the identified reason code from the resubmitted healthcare claim transaction; and

transmitting, by the one or more service provider computers, the modified resubmitted healthcare claim transaction to the claims processor computer that is identified by the destination identifier and that is associated with a claims processor for adjudication, wherein transmitting comprises routing the modified resubmitted healthcare claim transaction to the claims processor computer in accordance with a routing table associated with the one or more service provider computers.

18. The computer-implemented method of claim 17,

further comprising:

receiving, by the one or more service provider computers, an adjudicated response to the modified resubmitted healthcare claim transaction; and

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

19. A system for determining patient intervention services, the system comprising:

at least one memory operable to store computer-executable instructions; 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 associated with a pharmacy, a healthcare claim transaction comprising first data comprising a first prescription number, a first fill number, a first pharmacy identifier, a first date of service, a first product identifier for a prescribed product, a first patient identifier identifying a patient to receive the prescribed product and a destination identifier;

in response to receipt of the healthcare claim transaction, determine whether (1) at least one intervention service is available for the patient identified by the first patient identifier in the healthcare claim transaction based upon a review of patient eligibility information from a patient eligibility file accessible by the system, (2) the intervention service is contracted for by a claims processor computer identified by the destination identifier based upon a review of claims processor eligibility information from a eligible claims processor file accessible by the system and (3) the pharmacy that provided the healthcare claim transaction has contracted to receive intervention service notifications based upon a review of pharmacy eligibility information from a pharmacy eligibility file accessible by the system, wherein the intervention service available for the patient comprises at least one of wellness screening, blood pressure monitoring, medication therapy management services, immunization messaging, cash prescription monitoring, refill adherence, high-risk medication monitoring or diabetic screening or monitoring;

in an instance in which a determination is made that the intervention service is available for the patient, the intervention service is contracted for by the claims processor computer and the pharmacy has contracted to receive intervention service notifications, generate a reject response to the healthcare claim transaction, wherein the reject response comprises an indicator of the intervention service available for the patient, and wherein an intervention parameter file identifies a plurality of screening parameters for the intervention service;

direct communication of the reject response to the pharmacy computer, wherein the reject response to the healthcare claim transaction is transmitted prior to adjudication of the healthcare claim transaction by the claims processor computer and includes an indication that the healthcare claim transaction should be resubmitted;

receive, from the pharmacy computer and subsequent to the communication of the reject response, a resubmitted healthcare claim transaction comprising second data comprising a second prescription number, a second fill number, a second pharmacy identifier, a second date of service, and the patient identifier identifying the patient;

compare at least a portion of the first data to at least a portion of the second data to determine if a match exists between the portion of the first data and the portion of the second data;

in an instance in which the healthcare claim transaction is for an intervention service available to the patient and in which the resubmitted healthcare claim transaction includes a screening parameter for the intervention service, repeat the steps of generating the reject response, transmitting the reject response, receiving another resubmitted healthcare claim transaction including other data and another screening parameter for the intervention service and comparing at least a portion of the first data to a least a portion of the other data to determine if a match exists, wherein repeating the steps comprises evaluating the plurality of screening parameters from the intervention parameter file that are to be requested; and

in an instance in which at least one screening parameter remains to be requested, incrementing a counter variable that designates the screening parameter to be requested prior to repeating the steps;

otherwise, determine, based at least in part on the comparison, that the healthcare claim transaction is not for an intervention service available to the patient;

parse, based at least on the determination that the resubmitted healthcare claim transaction is not for an intervention service available to the patient, the resubmitted healthcare claim transaction to identify a reason code, wherein the reason code designates a reason that the intervention service available to the patient was not completed;

store the identified reason code;

modify the resubmitted healthcare claim transaction by removing the identified reason code from the resubmitted healthcare claim transaction; and

direct communication of the modified resubmitted healthcare claim transaction to the claims processor computer that is identified by the destination identifier and that is associated with a claims processor for adjudication, wherein the modified resubmitted healthcare claim transaction is transmitted by routing the modified resubmitted healthcare claim transaction to the claims processor computer in accordance with a routing table associated with the system.

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

receive an adjudicated response to the modified resubmitted healthcare claim transaction; and

direct communication of the adjudicated response to the pharmacy computer.