System and method for submitting medication claims by point-of-care physicians

• US 20080288281A1
• Filed: 05/17/2007
• Published: 11/20/2008
• Est. Priority Date: 05/17/2007
• Status: Active Grant

• Current Assignee: Targeted Medical Pharma, Inc.
• Original Assignee: Targeted Medical Pharma, Inc.
• Inventors: Shell, William E., Charuvastra, Elizabeth
• Granted Patent: US 8,370,172 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 20/13 delivered from dispensers

Abstract

A system for submitting a claim for a dispensed medication to a patient by a point-of-care physician including means acquiring at least one of the group consisting of a national practitioner number and a non pharmacy dispensing number for the point-of-care physician; means for displaying to a user a selection of data fields relating to the claim; means for inputting into the data fields data relating to the claim including the at least one of the group consisting of the national practitioner identifier number and the non pharmacy dispensing number; means for transmitting to a logic switch the claim containing the at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number identifying the point-of-care physician for determining the processor for the claim; means for determining the pathway for the claim based on a type of payor associated with the patient; means for processing the claim containing the at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number to identify the point-of-care physician; and responsive to the means for processing, means for transmitting to the point-of-care physician an adjudication regarding the claim.

Claims

1. A method for submitting a claim for a dispensed medication to a patient by a point-of-care physician comprising:

acquiring at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number for said point-of-care physician;

displaying to a user a selection of data fields relating to said claim;

inputting into said data fields data relating to said claim including said at least one of the group consisting of said national practitioner identifier number and said non pharmacy dispensing number,

transmitting to a logic switch said claim containing said at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number identifying said point-of-care physician for determining the processor for said claim;

determining the pathway for said claim based on a type of payor associated with said patient;

processing said claim containing said at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number to identify said point-of-care physician; and

responsive to said processing, transmitting to said point-of-care physician an adjudication regarding said claim.

2. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said determining said pathway comprises:

processing said national practitioner identifier number and a non pharmacy dispensing number when payor is Medicare Part D.

3. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said determining said pathway comprises:

processing said national practitioner identifier number when payor is Medicare Part B.

4. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said determining said pathway comprises:

processing said national practitioner identifier number and a non pharmacy dispensing number when payor is private insurance.

5. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said determining said pathway comprises:

processing said national practitioner identifier number when payor is worker'"'"'s compensation.

6. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said processing further comprises

determining the appropriate form on which to submit said claim, wherein said form is selected from the group consisting of a 1500 form, a universal drug form, and a computerized NCPDP 5.1 link

7. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said type of payor is selected from the group consisting of PPO private insurance, HMO private insurance, Medicare Part B, Medicare Part D, Champus, and Medicaid.

8. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said data fields are selected from the group consisting of transaction format for prescription, BIN, version number, transaction code, processor code, pharmacy number, group number, cardholder identification number, date of fill, prescription number, response format, response status, response data, claim reversal format, date of fill, prescription number, worker'"'"'s compensation claim format, Medicare claim format, claim payable response format, and claim captured response format.

9. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 further comprising:

reimbursing said point-of-care physician for said submitted pharmaceutical claim.

10. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 further comprising:

verifying the existence of a contract between said point-of-care physician and said payor.

11. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 further comprising:

obtaining a contract between said point-of-care physician and said payor.

12. The method for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said adjudication comprises a message containing information related to said processed claim selected from the group consisting of status of receipt by said processor, status of review by said processor, and status of disposition.

13. A system for submitting a claim for a dispensed medication to a patient by a point-of-care physician comprising:

means acquiring at least one of the group consisting of a national practitioner number and a non pharmacy dispensing number for said point-of-care physician;

means for displaying to a user a selection of data fields relating to said claim;

means for inputting into said data fields data relating to said claim including said at least one of the group consisting of said national practitioner identifier number and said non pharmacy dispensing number;

means for transmitting to a logic switch said claim containing said at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number identifying said point-of-care physician for determining the processor for said claim;

means for determining the pathway for said claim based on a type of payor associated with said patient;

means for processing said claim containing said at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number to identify said point-of-care physician; and

responsive to said means for processing, means for transmitting to said point-of-care physician an adjudication regarding said claim

14. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said means for determining said pathway comprises:

means for processing said national practitioner identifier number and a non pharmacy dispensing number when payor is Medicare Part D.

15. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said means for determining said pathway comprises:

means for processing said national practitioner identifier number when payor is Medicare Part B.

16. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said means for determining said pathway comprises:

means for processing said national practitioner identifier number and a non pharmacy dispensing number when payor is private insurance.

17. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said means for determining said pathway comprises:

means for processing said national practitioner identifier number when payor is worker'"'"'s compensation.

18. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said means for processing further comprises

means for determining the appropriate form on which to submit said claim, wherein said form is selected from the group consisting of a 1500 form, a universal drug form, and a computerized NCPDP 5.1 link

19. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said type of payor is selected from the group consisting of PPO private insurance, HMO private insurance, Medicare Part B, Medicare Part D, Champus, and Medicaid.

20. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said data fields are selected from the group consisting of transaction format for prescription, BIN, version number, transaction code, processor code, pharmacy number, group number, cardholder identification number, date of fill, prescription number, response format, response status, response data, claim reversal format, date of fill, prescription number, worker'"'"'s compensation claim format, Medicare claim format, claim payable response format, and claim captured response format.

21. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 further comprising:

means for reimbursing said point-of-care physician for said submitted pharmaceutical or Medical Food claim

22. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 further comprising:

means for verifying the existence of a contract between said point-of-care physician and said payor.

23. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 further comprising:

means for obtaining a contract between said point-of-care physician and said payor.

24. The system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 13 wherein said adjudication comprises a message containing information related to said processed claim selected from the group consisting of status of receipt by said processor, status of review by said processor, and status of disposition.

25. An electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician comprising:

an electronic input device for producing input signals;

a display;

an electronic memory storing at least one of the group consisting of national practitioner identifier number, non pharmacy dispensing number, transaction format for prescription, BIN, version number, transaction code, processor code, pharmacy number, group number, cardholder identification number, date of fill, prescription number, response format, response status, response data, claim reversal format, date of fill, prescription number, worker'"'"'s compensation claim format, Medicare claim format, claim payable response format, and claim captured response format; and

an electronic processor communicating with said memory and said display and responsive to the input signals to;

direct said display to display a data field relating to said at least one of said group consisting of national practitioner identifier number, non pharmacy dispensing number, transaction format for prescription, BIN, version number, transaction code, processor code, pharmacy number, group number, cardholder identification number, date of fill, prescription number, response format, response status, response data, claim reversal format, date of fill, prescription number, worker'"'"'s compensation claim format, Medicare claim format, claim payable response format, and claim captured response format;

receive input into said data field relating to said claim including said at least one of the group consisting of said national practitioner identifier number and said non pharmacy dispensing number,

transmit to a logic switch said claim containing said at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number identifying said point-of-care physician for determining the processor for said claim;

determine the pathway for said claim based on a type of payor associated with said patient;

process said claim containing said at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number to identify said point-of-care physician; and

responsive to said processing, transmit to said point-of-care physician an adjudication regarding said claim.

26. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 25 wherein the electronic processor is further responsive to the input signals to:

process said national practitioner identifier number and a non pharmacy dispensing number when payor is Medicare Part D.

27. The system as in claim 25 wherein the electronic processor is further responsive to the input signals to display said IP release status.

28. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 25 wherein the electronic processor is further responsive to the input signals to:

process said national practitioner identifier number when payor is Medicare Part B.

29. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 25 wherein the electronic processor is further responsive to the input signals to:

process said national practitioner identifier number and a non pharmacy dispensing number when payor is private insurance.

30. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 25 wherein the electronic processor is further responsive to input signals to:

process said national practitioner identifier number when payor is worker'"'"'s compensation.

32. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 25 wherein said type of payor is selected from the group consisting of PPO private insurance, HMO private insurance, Medicare Part B, Medicare Part D, Champus, and Medicaid.

36. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 25 wherein said adjudication comprises a message containing information related to said processed claim selected from the group consisting of status of receipt by said processor, status of review by said processor, and status of disposition.

31. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of 25 wherein the electronic processor is further responsive to input signals to:

determine the appropriate form on which to submit said claim, wherein said form is selected from the group consisting of a 1500 form, a universal drug form, and a computerized NCPDP 5.1 link.

33. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of 25 wherein the electronic processor is further responsive to input signals to:

determine the appropriate form on which to submit said claim, wherein said form is selected from the group consisting of a 1500 form, a universal drug form, and a computerized NCPDP 5.1 link.

34. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of 25 wherein the electronic processor is further responsive to input signals to:

verify the existence of a contract between said point-of-care physician and said payor.

35. The electronic system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of 25 wherein the electronic processor is further responsive to input signals to:

obtain a contract between said point-of-care physician and said payor.