Prescription creation and adjudication method

• US 20040153336A1
• Filed: 02/04/2003
• Published: 08/05/2004
• Est. Priority Date: 02/04/2003
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Express Scripts Incorporated (The Cigna Group)
• Inventors: Rey-Giraud, Agnes, Stuart, Mike, Virdee, Pritpal S., Wingate, Elizabeth S.
• Granted Patent: US 8,099,295 B2
• 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

Abstract

The invention provides a computer-implemented method for creating a prescription for treatment of an injury or illness covered by a workers'"'"' compensation system, which facilitates on-line adjudication of a workers'"'"' compensation claim. The patient name, employer name and type and quantity of medication prescribed are input. Routing data including a processor identification number is retrieved from an employer database. The program outputs prescription data comprising the name of the patient, the type and quantity of medication prescribed, and the routing data. The prescription data is preferably NCPDP compliant and used by a pharmacy to route a workers'"'"' compensation claim and fill the prescription.

Claims

1. A computer-implemented method for creating a prescription, which facilitates on-line adjudication of a prescription drug claim, the method comprising:

a. receiving input data identifying a patient and a type and quantity of medication prescribed;

b. providing a database for associating the input data with routing data comprising data identifying a processor;

c. retrieving the routing data from the database; and

d. outputting prescription data comprising an identification of the patient, the type and quantity of medication prescribed, and the routing data,

whereby the prescription data can be received by a pharmacy to route a claim to the processor for on-line adjudication and to fill the prescription.

2. The method of claim 1, wherein the prescription is covered by a workers'"'"' compensation system, and the input data further comprises data identifying an employer, and the database comprises data for associating the data identifying the employer with data identifying the processor.

3. The method of claim 1, wherein the step of outputting prescription data comprises the steps of:

a. printing a prescription comprising an identification of the patient and the type and quantity of medication; and

b. printing an identification card comprising an identification of the patient and the routing data.

4. The method of claim 1, wherein the prescription data complies with NCPDP standards.

5. The method of claim 1, wherein the step of outputting the prescription data comprises the step of printing a prescription comprising an identification of the patient, an identification of the type and quantity of medication prescribed, and the routing data.

6. The method of claim 1, wherein the step of outputting the prescription data comprises the step of electronically transmitting the prescription data to a pharmacy.

7. A computer-implemented method for creating a prescription for treatment of an injury or illness covered by a workers'"'"' compensation system, which facilitates on-line adjudication of a workers'"'"' compensation claim, the method comprising:

a. receiving data identifying a patient, an employer, and a type and quantity of medication prescribed;

b. providing an employer database for associating the data identifying the employer with routing data comprising data identifying a processor;

c. retrieving the routing data from the employer database; and

d. outputting prescription data comprising an identification of the patient, the type and quantity of medication prescribed, and the routing data,

whereby the prescription data can be received by a pharmacy to route a claim to the processor for on-line adjudication and to fill the prescription.

8. The method of claim 7, wherein the routing data further comprises data identifying a workers'"'"' compensation carrier or employer.

9. The method of claim 8, wherein the employer database further comprises coverage data comprising a term of coverage associated with the workers'"'"' compensation carrier or employer, the method further comprising the steps of:

a. receiving a date of injury;

b. retrieving coverage data associated with the workers'"'"' compensation carrier or employer; and

c. determining whether the date of injury falls within the term of coverage.

10. The method of claim 9, further comprising the steps of:

a. generating a claim identifier associated with the injury; and

b. outputting prescription data further comprising the claim identifier.

11. The method of claim 7, wherein the step of outputting prescription data comprises the steps of:

a. printing a prescription comprising an identification of the patient and the type and quantity of medication; and

b. printing an identification card comprising an identification of the patient and the routing data.

12. The method of claim 7, wherein the prescription data complies with NCPDP standards.

13. The method of claim 7, wherein the step of outputting the prescription data comprises the step of printing a prescription comprising an identification of the patient, an identification of the type and quantity of medication prescribed, and the routing data.

14. The method of claim 7, wherein the step of outputting the prescription data comprises the step of electronically transmitting the prescription data to a pharmacy.

15. The method of claim 7, further comprising the steps of:

a. receiving data identifying a preferred pharmacy location;

b. providing a pharmacy database containing data identifying a plurality of pharmacies and associated locations;

c. retrieving from the pharmacy database pharmacy data comprising data identifying one or more of the plurality of pharmacies near the preferred pharmacy location; and

d. outputting prescription data further comprising an identification of the one or more retrieved pharmacies.

16. The method of claim 7, further comprising:

a. providing a patient database for storing data associated with a plurality of patients; and

b. storing and retrieving data relating to the patient in the patient database.

17. A computer-implemented method for creating a prescription for treatment of an injury or illness covered by a workers'"'"' compensation system, which facilitates on-line adjudication of a workers'"'"' compensation claim, the method comprising:

a. receiving data comprising a name of the patient, a name of the employer, and a name and a quantity of medication prescribed;

b. providing an employer database for associating the employer name with an identification number associated with a processor;

c. retrieving the processor identification number associated with the employer name from the employer database; and

d. outputting a prescription comprising the name of the patient, the name and quantity of medication prescribed, and the processor identification number,

whereby the prescription can be received by a pharmacy for use in filling the prescription and routing a claim to the processor for on-line adjudication.

18. A computer-implemented method for creating a prescription for treatment of an injury or illness covered by a workers'"'"' compensation system, which facilitates on-line adjudication of a workers'"'"' compensation claim, the method comprising:

a. receiving data comprising a name of the patient, a name of the employer, a name and a quantity of medication prescribed;

b. providing an employer database for associating the employer name with an identification number associated with a processor;

c. retrieving the processor identification number associated with the employer name from the employer database;

d. outputting a prescription comprising the name of the patient and the name and quantity of medication prescribed; and

e. outputting an identification card comprising the name of the patient and the processor identification number,

whereby the prescription and identification card can be received by a pharmacy for use in filling the prescription and routing a claim to the processor for on-line adjudication.

19. A computer-implemented method for on-line adjudication of a claim for a prescription covered by a workers'"'"' compensation system, the method comprising:

a. providing a processor for receiving a claim from a pharmacy electronically and adjudicating the claim;

b. receiving data identifying a patient, an employer, and a type and quantity of medication prescribed;

c. providing an employer database for associating the data identifying the employer with routing data comprising data identifying the processor;

d. retrieving the routing data from the employer database;

e. outputting prescription data comprising an identification of the patient, the type and quantity of medication prescribed, and the routing data;

f. receiving a claim transmitted by a pharmacy;

g. determining whether the claim satisfies predetermined criteria for approval; and

h. electronically routing a claim approval or disapproval message to the pharmacy.

20. The method of claim 19, wherein the prescription data is electronically transmitted to a pharmacy.

21. The method of claim 19, wherein the prescription data is printed and delivered to a pharmacy.

22. The method of claim 19, wherein the step of outputting prescription data comprises the steps of printing a prescription comprising an identification of the patient, the type and quantity of medication prescribed, and the routing data.

23. The method of claim 19, wherein the step of outputting prescription data comprises the steps of printing a prescription comprising an identification of the patient and the type and quantity of medication prescribed, and an identification card comprising and identification of the patient and the routing data.

24. A computer-implemented method for facilitating on-line adjudication of a workers'"'"' compensation claim for a prescription for treatment of a an injury or illness covered by a workers'"'"' compensation system, the method comprising:

a. receiving data comprising a name of a patient, a name of an employer, a name and quantity of medication prescribed, and a date of the injury;

b. providing an employer database comprising data for determining if the date of injury falls within a term of coverage associated with the employer and for associating the name of the employer with routing data comprising a processor identification number;

c. determining if the date of injury falls within the term of coverage;

d. retrieving the routing data from the employer database if the date of injury falls within the term of coverage;

e. outputting a prescription and the routing data;

f. delivering the prescription and routing data to a pharmacy;

g. using the routing number to electronically route a claim to the processor for approval;

h. determining whether the claim satisfies predetermined criteria for approval; and

i. electronically routing a claim approval or disapproval message to the pharmacy.

25. A prescription comprising:

a. data identifying a patient and a type and quantity of medication prescribed; and

b. routing data comprising data identifying a processor;

whereby the prescription can be received by a pharmacy to route a claim to the processor for on-line adjudication and to fill the prescription.

26. The prescription of claim 25, wherein the prescription is printed.

27. The prescription of claim 25, wherein the prescription is electronically transmitted to the pharmacy.

28. The prescription of claim 25, wherein the routing data complies with NCPDP standards.

29. The prescription of claim 25, wherein the prescription is covered by a workers'"'"' compensation system and the routing data comprises data identifying a workers'"'"' compensation carrier.