Apparatus and method for managing prescription benefits

• US 20070082543A1
• Filed: 12/07/2006
• Published: 04/12/2007
• Est. Priority Date: 01/22/2002
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Juravel, Zev, Carlson, Mark, Alexander, Jeffrey, Healy, Richard, Taylor, Nicholas, Jackson, William, Stettin, Glen
• Granted Patent: US 7,774,213 B2
• Time in Patent Office: Days
• US Class Current: 439/535
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: Y10S 707/99933 Query processing, i.e. searching

Abstract

A system and method are disclosed for managing prescription benefits. Case records containing information regarding patients and prescription coverage activities for the patients are stored in the system. Users are allowed access to the system via an appropriate electronic communication network. The user can subsequently perform various tasks in order to maintain and review coverage activities. The user can also enter additional prescription coverage activities into the case records, as well as verify that information entered into the case records has been updated.

Claims

1. :

A method of managing prescription benefits offered by a plurality of providers comprising;

storing prescription benefit case records in a prescription benefits management system for patients receiving prescription benefits coverage for the plurality of healthcare providers, said prescription benefit case records containing information regarding the patients and prescription coverage activities for the patient;

providing access to said prescription benefits management system by the plurality of providers of prescription benefits over one or more electronic communication networks;

accessing by a user said prescription benefits management system from remote locations via one or more electronic communication networks;

conducting an inquiry on said prescription benefit case records to view and reviewing selected prescription coverage activities contained in said prescription benefit case records,

inputting additional prescription coverage activities into said case records, if necessary,

verifying that said case records have been updated, if additional prescription coverage activities will not be inputted,

displaying an activity report containing all prescription coverage activities and reference data for the prescription benefit case record,

displaying coverage activity details for the selected prescription benefit case record, the coverage activity details including at least a list of prescription products, a list of coverage prescription products, and a list of prescription product categories,

displaying one or more reasons for each prescription coverage denial, and reviewing details of the displayed reasons, and at least one of overriding the displayed prescription coverage denial based on one or more clinical and prescription criteria, replacing an original prescription product with a substitute prescription product that is covered by a prescription benefit plan associated with the case record, and appealing the prescription coverage denial based on clinical reasons in response to receiving a request from a user,

accessing a new prescription benefit case record for prescription benefits currently being viewed by a second user,

releasing the new prescription case record without the second user'"'"'s authorization,

modifying information contained in the prescription benefit case record, and

closing said prescription benefit case records.

2. :

The method of claim 1 further comprising a step of accessing at least one of a help manual and a user manual stored in electronic form on the prescription benefit management system to obtain instructions for assisting in operating the system.

3. :

The method of claim 1, further comprising a step of displaying a status report identifying at least approvals/denials of claims for prescription coverage.

4. :

The method of claim 1, further comprising a step of viewing a reference library containing a collection of documents used to support decisions made on a case record.

5. :

The method of claim 1, wherein the step of accessing further comprises a step of displaying case activity details corresponding to either specific information on the patient or prescription coverage activities for the patient, after the case record has been accessed.

6. :

The method of claim 1, wherein the step of conducting further comprises the steps;

inquiring on communication items relating to the case record; and

displaying details of all communication items that have occurred in the case record, including at least the medium and direction of each communication item.

7. :

The method of claim 1, further comprising a step of reviewing a coverage criteria for the case record subsequent to the step of conducting an inquiry, wherein the coverage criteria comprises information which led to a particular decision on the case record.

8. :

The method of claim 1, further comprising a step of displaying an activity report containing all prescription coverage activities and reference data for the case record.

9. :

The method of claim 1, further comprising a step of displaying coverage activity details for the selected case record, the coverage activity details including at least a list of products, a list of coverage products, and a list of product categories.

10. :

The method of claim 1, wherein the selected case record contains at least one prescription coverage denial, and further comprising the steps;

displaying one or more reasons for each coverage denial; and

reviewing details of the displayed reasons.

11. :

The method of claim 10, wherein the case record is being reviewed by an administrator and further comprising a step of overriding the displayed coverage denial based on one or more clinical criteria.

12. :

The method of claim 10, further comprising a step of processing appealing the coverage denial based on clinical reasons, and wherein the coverage denial may be reversed or upheld.

13. :

The method of claim 12, wherein the step of processing an appeal further includes a step of replacing an original prescription product with a substitute prescription product that is covered by a prescription benefit plan associated with the case record.

14. :

The method of claim 12, wherein the step of processing an appeal further comprises the step of viewing entries generated by prior reviews of at least one of the case record and any coverage denials thereof.

15. :

The method of claim 1, further comprising a step of creating a new review for the selected case record, and entering prescription coverage activity information for the case record.

16. :

The method of claim 1, wherein an administrator is accessing the case record, and further comprising the steps;

changing a security status of the selected case record from a locked status to an unlocked status; and

entering changes to one or more case parameters.

17. :

The method of claim 16, further comprising a step of generating correspondence to be sent to a patient identified in the case record.

18. :

The method of claim 1, further comprising a step of automatically generating status reports for one or more clients at predetermined intervals.

19. :

The method of claim 1, further comprising a step of automatically generating and maintaining a record of all transactions performed while using the prescription benefits management system.

20. A system for managing prescription benefits offered by a plurality of providers comprising:

a prescription benefits management system, for storing prescription benefit case records for patients receiving prescription benefits coverage for the plurality of healthcare providers, said prescription benefit case records containing information regarding the patients and prescription coverage activities for the patient;

a communication device operatively coupled to said prescription benefits management system for providing access to said prescription benefits management system by the plurality of providers of prescription benefits over one or more electronic communication networks; and

at least one user computer for accessing said prescription benefits management system from remote locations via said one or more electronic communication networks;

said prescription benefits management system being configured to allow users to;

conduct an inquiry on said prescription benefit case records to view and review selected prescription coverage activities contained in said prescription benefit case records,

input additional prescription coverage activities into said case records, if necessary,

verify that said case records have been updated, if additional prescription coverage activities will not be inputted,

display an activity report containing all prescription coverage activities and reference data for the prescription benefit case record,

display coverage activity details for the selected prescription benefit case record, the coverage activity details including at least a list of prescription products, a list of coverage prescription products, and a list of prescription product categories,

display one or more reasons for each prescription coverage denial, and reviewing details of the displayed reasons, and at least one of overriding the displayed prescription coverage denial based on one or more clinical and prescription criteria, replacing an original prescription product with a substitute prescription product that is covered by a prescription benefit plan associated with the case record, and appealing the prescription coverage denial based on clinical reasons in response to receiving a request from a user,

access a new prescription benefit case record for prescription benefits currently being viewed by a second user,

release the new prescription case record without the second user'"'"'s authorization,

modify information contained in the prescription benefit case record, and

close said prescription benefit case records.

21. A method of managing prescription benefits offered by a plurality of providers, comprising:

storing prescription benefit case records in at least a prescription benefits management system for patients receiving prescription benefits coverage for the plurality of healthcare providers, said prescription benefit case records containing at least information regarding the patients and prescription coverage activities for the patient;

providing access to said prescription benefits management system by the plurality of providers of prescription benefits over one or more electronic communication networks;

accessing by a user said prescription benefits management system via the one or more electronic communication networks;

conducting an inquiry on said prescription benefit case records to view and reviewing selected prescription coverage activities contained in said prescription benefit case records,

inputting additional prescription coverage activities into said case records, when necessary,

verifying that said case records have been updated,

determining whether the user is a clinical user,

when the user is determined to be the a clinical user, generating an activity report containing all prescription coverage activities and reference data for the prescription benefit case record,

generating coverage activity details for the selected prescription benefit case record, the coverage activity details including at least a list of prescription products, a list of coverage prescription products, and a list of prescription product categories,

generating one or more reasons for each prescription coverage denial, and reviewing details of the displayed reasons, and at least one of overriding the displayed prescription coverage denial based on one or more clinical and prescription criteria, replacing an original prescription product with a substitute prescription product that is covered by a prescription benefit plan associated with the case record, and appealing the prescription coverage denial based on clinical reasons in response to receiving a request from a user,

accessing a new prescription benefit case record for prescription benefits currently being viewed by a second user,

releasing the new prescription case record without the second user'"'"'s authorization,

modifying information contained in the prescription benefit case record, and

closing said prescription benefit case records.