Apparatus and method for constructing and managing clinical rules

• US 20030139945A1
• Filed: 01/07/2003
• Published: 07/24/2003
• Est. Priority Date: 01/22/2002
• Status: Abandoned Application

• Current Assignee: Merck-Medco Managed Care LLC (Merck & Co., Inc.)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Brisson, Paul R., Brown, Kenneth J., Stettin, Glen D., Tobin, William D.
• Application Number:
  US10/337,371
• Publication Number:
  US 20030139945A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

An apparatus and method are disclosed for defining and managing clinical rules. A computer system provides access to administrators for defining and entering the details of clinical rules for various clients. The administrator selects the prescription products, or medication, for which the clinical rule will apply. The administrator also specifies the coverage criteria to be used for approving coverage of the prescription products. When a prescription claim is submitted to the computer system, the appropriate clinical rule is selected and applied to determine if the cost of the prescription product should be covered.

Claims

1. A method of creating clinical rules for approving coverage of prescription products comprising the steps:

selecting at least one service classification for a clinical rule;

selecting at least one prescription product for the clinical rule;

selecting at least one treatment type for each selected prescription product;

selecting predetermined medical conditions treatable by the prescription products under each clinical rule, based on the defined service classifications; and

specifying at least one coverage criteria for approving coverage of each selected prescription product.

2. The method of claim 1, further comprising inputting clinical messages regarding the prescription product for each clinical rule.

3. The method of claim 2, wherein the clinical messages provide information regarding coverage limits for the prescription product.

4. The method of claim 2, wherein different clinical messages are provided for retail pharmacies and mail order pharmacies.

5. The method of claim 1, further comprising inputting patient messages regarding the prescription product for each coverage criteria.

6. The method of claim 5, further comprising the steps:

establishing a communication channel with a patient computer; and

providing access to the patient messages across the communication channel.

7. The method of claim 1, further comprising selecting predetermined physical criteria to support coverage of the prescription product.

8. The method of claim 7, wherein selecting predetermined physical criteria includes a step of selecting at least one of gender, age, and weight.

9. The method of claim 1, further comprising inputting adverse interactions that can result from using the prescription product.

10. The method of claim 9, wherein inputting includes a step of providing a link to a patient'"'"'s prescription history to identify prescription products that have been, or are currently, used by the patient.

11. The method of claim 10, further comprising defining a predetermined time interval within the patient'"'"'s clinical history to be reviewed.

12. The method of claim 1, further comprising defining at least one delivery method for administering the prescription products.

13. The method of claim 12, further comprising calculating equivalent dosages of the prescription products for different delivery methods.

14. The method of claim 1, wherein the step of selecting at least one service classification further includes selecting a service category and a treatable condition for each selected service classification.

15. The method of claim 1, wherein the step of selecting at least one treatment type includes a step of selecting a combination of one or more treatment types from the group of treatment types consisting of quantity, duration, step therapy, and treatment history qualification.

16. The method of claim 15, wherein the treatment type is a quantity treatment, and further comprising the steps:

providing a link to the patient'"'"'s clinical history; and

specifying, in the coverage criteria, that the prescription product should be covered only if the patient has previously used a predetermined quantity of the same prescription product for the medical condition.

17. The method of claim 15, wherein the treatment type is a duration treatment, and further comprising the steps:

providing a link to the patient'"'"'s clinical history; and

specifying, in the coverage criteria, that the prescription product should be covered only if the patient has previously used the same prescription product for a predetermined length of time for the same medical condition.

18. The method of claim 15, wherein the treatment type is a step therapy treatment, and further comprising the steps:

providing a link to the patient'"'"'s clinical history; and

specifying, in the coverage criteria, that the prescription product should be covered only if the patient has previously used a milder prescription product for the same medical condition.

19. The method of claim 15, wherein the treatment type is a treatment history qualification, and further comprising the steps:

providing a link to the patient'"'"'s clinical history; and

specifying, in the coverage criteria, that the prescription product should be covered only if the patient'"'"'s clinical history indicates a pattern of predetermined treatment types prescription product for the same medical condition.

20. The method of claim 15, further comprising the steps:

selecting multiple treatment types; and

linking selected treatment types to a single coverage criteria.

21. The method of claim 1, further comprising the steps of providing an operator with a graphical interface, and wherein at least one of the steps of defining, selecting at least one treatment type, selecting predetermined medical conditions, and identifying is performed using an input device.

22. The method of claim 1, further comprising the steps of providing an operator with a graphical interface, and wherein at least one of the steps of defining, selecting at least one treatment type, selecting predetermined medical conditions, and identifying is performed using a graphical/cursor control device.

23. A method of evaluating prescription claims using predefined clinical rules, comprising the steps:

determining whether at least one prescription product in a prescription claim are included in a prescription benefits plan of at least one client;

retrieving a plurality of clinical rules from the prescription benefit plan; and

applying at least one of the plurality of clinical rules to the at least one prescription product to determine whether the prescription claim is reimbursable, at least in part, with respect to the at least one prescription product.

24. The method of claim 23, wherein the step of applying further includes a step of comparing physical criteria contained in the clinical rule with patient criteria.

25. The method of claim 23, wherein the step of applying further includes a step of comparing treatment types contained in the clinical rules with a treatment type specified in the prescription claim.

26. The method of claim 23, wherein the step of applying further comprises a step of comparing medical conditions contained in the clinical rules with a medical condition specified in the prescription claim.

27. The method of claim 23, wherein the step of applying further comprises the steps:

comparing prescription products in the patients clinical history with the prescription products in the prescription claim; and

identifying adverse reactions that can result from using the prescription products in the patient'"'"'s clinical history simultaneously with the prescription products in the prescription claim.

28. The method of claim 23, further comprising a step of determining a treatment type for each prescription product in the prescription claim.

29. The method of claim 28, wherein the treatment type is a quantity treatment, and further comprising the steps:

reviewing the patient'"'"'s clinical history; and

accepting coverage for the prescription product only if the patient has previously used a predetermined quantity of the same prescription product for the same medical condition.

30. The method of claim 28, wherein the treatment type is a duration treatment, and further comprising the steps:

reviewing the patient'"'"'s clinical history; and

accepting coverage for the prescription product only if the patient has previously used the same prescription product for a predetermined length of time for the same medical condition.

31. The method of claim 28, wherein the treatment type is a step therapy treatment, and further comprising the steps:

reviewing the patient'"'"'s clinical history; and

accepting coverage for the prescription product only if the patient has previously used a milder prescription product for the same medical condition.

32. The method of claim 28, wherein the treatment type is a treatment history qualification, and further comprising the steps:

reviewing the patient'"'"'s clinical history; and

accepting coverage for the prescription product only if the patient'"'"'s clinical history indicates a pattern of predetermined treatment types prescription product for the same medical condition.

33. The method of claim 23, further comprising a step of assessing the severity of a patient'"'"'s medical condition.

34. The method of claim 33, wherein the step of assessing further comprises the steps:

reviewing the patient'"'"'s clinical history to identify prescription products which have been prescribed to the patient;

determining the medical conditions that are treatable by identified prescription products; and

identifying one or more correlations between the medical conditions and prescription products.

35. The method of claim 34, further comprising a step of identifying trends in dosage of a prescription product taken by a patient for one of the determined medical conditions.

36. A method of creating clinical rules for approving coverage of prescription products comprising the steps:

selecting at least one service classification for each of a plurality of clinical rules;

selecting at least one prescription product for the at least one of the plurality of clinical rules;

selecting at least one treatment type for each selected prescription product;

selecting predetermined medical conditions treatable by the prescription products under each of the plurality of clinical rules, based on the defined service classifications;

specifying at least one coverage criteria for approving coverage of each selected prescription product;

selecting predetermined physical criteria to support coverage of the prescription product; and

inputting clinical messages regarding the prescription product for each clinical rule.

37. A method of creating clinical rules for approving coverage of prescription products comprising the steps:

selecting at least one service classification for a clinical rule;

selecting at least one prescription product for the clinical rule;

selecting a combination of one or more treatment types for each selected product from the group of treatment types consisting of quantity, duration, step therapy, and treatment history qualification;

selecting predetermined medical conditions treatable by the prescription products under each clinical rule, based on the defined service classifications;

specifying at least one coverage criteria for approving coverage of each selected prescription product; and

defining at least one delivery method for administering the prescription products.

38. A method of evaluating prescription claims using predefined clinical rules, comprising the steps:

determining if one or more prescription products in a prescription claim are included in a client'"'"'s prescription benefits plan;

retrieving a plurality of clinical rules from the client'"'"'s prescription benefit plan;

determining a treatment type for each prescription product in the prescription claim;

applying an appropriate clinical rule to each prescription product to determine if the prescription claim should be covered, at least in part, with respect to the prescription products; and

assessing the severity of a patient'"'"'s medical condition.

39. A method of evaluating prescription claims using predefined clinical rules, comprising the steps:

determining if one or more prescription products in a prescription claim are included in a client'"'"'s prescription benefits plan;

retrieving a plurality of clinical rules from the client'"'"'s prescription benefit plan;

comparing physical criteria contained in the clinical rule with patient criteria; and

comparing treatment types contained in the clinical rules with a treatment type specified in the prescription claim.

40. A method of evaluating prescription claims using predefined clinical rules, comprising the steps:

determining if one or more prescription products in a prescription claim are included in a client'"'"'s prescription benefits plan;

retrieving a plurality of clinical rules from the client'"'"'s prescription benefit plan;

comparing physical criteria contained in the clinical rule with patient criteria;

comparing treatment types contained in the clinical rules with a treatment type specified in the prescription claim;

comparing prescription products in the patients clinical history with the prescription products in the prescription claim; and

identifying adverse reactions that can result from using the prescription products in the patient'"'"'s clinical history simultaneously with the prescription products in the prescription claim.

41. A system for creating clinical rules, comprising:

a computer system;

at least one additional computer; and

a communication interface coupled to said computer system for establishing a communication channel with said at least one additional computer;

said computer being configured to facilitate;

selection of at least one service classification for a clinical rule,

selection of at least one prescription product for the clinical rule,

selection of at least one treatment type for each selected prescription product,

selection of predetermined medical conditions treatable by the prescription products under each clinical rule, based on the defined service classifications, and

specification of at least one coverage criteria for approving coverage of each selected prescription product.

42. A system for creating clinical rules, comprising:

a computer system;

at least one additional computer system; and

a communication interface coupled to said computer system for establishing a communication channel with said at least one additional computer system;

said computer system being configured to;

receive information corresponding to a prescription claim from said at least one additional computer;

determine if one or more prescription products in said prescription claim are included in a client'"'"'s prescription benefits plan;

retrieve a plurality of clinical rules from the client'"'"'s prescription benefit plan; and

apply an appropriate clinical rule to each prescription product to determine if said prescription claim should be covered, at least in part, with respect to said prescription products.

43. A method of creating clinical rules for approving coverage of prescription products comprising at least one of the sequential, non-sequential, and sequence independent steps:

selecting at least one service classification for at least one clinical rule;

selecting at least one prescription product for the at least one clinical rule;

selecting at least one treatment type for the at least one prescription product selected;

selecting predetermined medical conditions treatable by the at least one prescription product for the at least one clinical rule, based on the at least one service classification selected; and

specifying at least one coverage criteria for approving coverage of the at least one prescription product selected.

44. A method of evaluating prescription claims using predefined clinical rules, comprising the steps:

determining whether at least one prescription product in a prescription claim are included in a prescription benefits plan of at least one client;

retrieving a plurality of clinical rules from the prescription benefit plan;

determining a treatment type for each prescription product in the prescription claim; and

applying at least one of the plurality of clinical rules to the at least one prescription product to determine whether the prescription claim is reimbursable, at least in part, with respect to the at least one prescription product.