SYSTEMS AND METHODS FOR ACCELERATED PAYMENT OF PHARMACY PRESCRIPTION CLAIMS

• US 20070136100A1
• Filed: 08/25/2006
• Published: 06/14/2007
• Est. Priority Date: 08/26/2005
• Status: Abandoned Application

• Current Assignee: Adam Condie, Loraine Daugherty
• Original Assignee: Adam Condie, Loraine Daugherty
• Inventors: Daugherty, Loraine, Condie, Adam
• Application Number:
  US11/467,347
• Publication Number:
  US 20070136100A1
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/10 specially adapted for electronic funds transfer [EFT] systems; specially adapted for home banking systems
• CPC Class Codes: G06Q 30/00 Commerce
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods and systems are related to the payment of pharmacy benefits under an insurance policy. The system includes pharmacies, a real-time claims processing adjudication component, an information component and a claims processing or billing component. When a qualified patient submits a prescription to a participating pharmacy, the pharmacy collects identifying information from the patient and conveys a request to the real-time claims adjudication component, which screens the request for a match to data already loaded in the system and conveys a notification of acceptance or error to the pharmacy. The real-time claims adjudication component compiles records of the approved claims and the claims processing component processes the claims, bills third party payors and generates periodic files detailing payments owed to pharmacies. Funds are then made available to the pharmacy. The pharmacy may obtain the funds by initiating a transfer, such as a charge placed on a card issued by the system.

Claims

1. A method for accelerated payment of prescription benefits to a pharmacy, the method comprising:

receiving identifying information of a patient from a pharmacy;

adjudicating a request for prescription benefit coverage based on the identifying information;

conveying a notification to the pharmacy that the request for prescription benefit coverage is approved;

conveying a notification to the pharmacy that funds are available as payment for the prescription benefit coverage; and

providing a guaranteed payment for the prescription benefit coverage to the pharmacy by approving a charge to be placed on a charge card provided to the pharmacy by a claims management service.

2. The method according to claim 1, wherein receiving identifying information of a patient from a pharmacy comprises receiving identifying information for a patient eligible for worker'"'"'s compensation coverage.

3. The method according to claim 1, wherein receiving identifying information of a patient from a pharmacy comprises receiving identifying information selected from the group consisting of a name of the patient, the patient'"'"'s social security number, a name of the patient'"'"'s employer, a telephone number, an employer'"'"'s address, and the date of the injury for which the prescription is intended.

4. The method according to claim 1, wherein conveying a notification to the pharmacy that the request for prescription benefit coverage is approved comprises conveying a notification over a computer network.

5. The method according to claim 1, wherein conveying a notification to the pharmacy that funds are available as payment for the prescription benefit coverage comprises conveying a notification to the pharmacy that funds are available as payment for a number of prescriptions approved during a set time period.

6. The method according to claim 5, further comprising conveying a reconciliation file to the pharmacy, detailing the prescriptions for which the funds are available as payment.

7. The method according to claim 1, further comprising producing a periodic pharmacy payment file from the notification to the pharmacy that the request for prescription benefit coverage is approved.

8. The method according to claim 7, wherein the periodic pharmacy payment file is produced on a weekly basis.

9. The method according to claim 1, wherein providing a guaranteed payment for the prescription benefit coverage to the pharmacy by approving a charge to be placed on a charge card provided to the pharmacy by a claims management service comprises approving a charge for an amount specified in the notification that funds are available to be placed on a charge card.

10. The method according to claim 1, wherein providing a guaranteed payment for the prescription benefit coverage to the pharmacy by approving a charge to be placed on a charge card provided to the pharmacy by a claims management service comprises placing a charge on a charge card selected from the group consisting of a P card, a debit card, a credit card and a charge card.

11. The method according to claim 1, wherein providing a guaranteed payment for the prescription benefit coverage to the pharmacy by approving a charge to be placed on a charge card provided to the pharmacy by a claims management service comprises approving a charge that is placed on an account associated with the claims management service.

12. The method according to claim 11, wherein approving a charge that is placed on an account associated with the claims management service comprises approving a charge to be placed on a line of credit for which the claims management service is responsible.

13. The method according to claim 1, further comprising conveying a notification to the pharmacy that there is an error in the request for prescription benefit coverage following adjudicating the request for prescription benefit coverage based on the identifying information.

14. The method according to claim 13, further comprising assisting the pharmacy to revise the identifying information of a patient and receiving the revised identifying information of a patient.

15. A system for providing accelerated payment of prescription benefits to a pharmacy, the system comprising:

a real-time processing component for receiving a request for prescription benefits from a pharmacy, the real-time processing component configured to compare information collected from a patient to a database and to accept the request if a match is located and convey the acceptance to the pharmacy before a filled prescription is provided to the patient;

a claims processing component for downloading accepted requests from the real-time processing component and generate a bill to a third-party payor for the accepted request and to generate a periodic pharmacy payment file from the processed accepted requests; and

a payment processing component for releasing funds from a credit line to the pharmacy on a periodic basis in response to the periodic pharmacy payment file.

16. The system of claim 15, wherein the real-time processing component is configured to receive the periodic pharmacy payment file and to function as the payment processing component by releasing the funds to the pharmacy.

17. The system of claim 15, wherein the payment processing component is configured to convey a notification to the pharmacy that funds are available for payment.

18. The system of claim 17, wherein the payment processing component releases funds from a credit line to the pharmacy by making a charge available on a card issued to the pharmacy, the card selected from the group consisting of a P card, a debit card, a credit card and a charge card.

19. The system of claim 15, wherein the claims processing component is configured to release a reconciliation file detailing the accepted requests taken from the periodic pharmacy payment file to the pharmacy.

20. The system of claim 15, further comprising a help desk or information component for assisting the pharmacy in correcting an error in a request for benefits, if the request is refused by the real-time processing component.