SYSTEMS AND METHODS FOR MANAGING PHARMACY CLAIMS

• US 20130110555A1
• Filed: 11/02/2011
• Published: 05/02/2013
• Est. Priority Date: 11/02/2011
• Status: Abandoned Application

• Current Assignee: The Travelers Indemnity Company (The Travelers Cos., Inc.)
• Original Assignee: The Travelers Indemnity Company (The Travelers Cos., Inc.)
• Inventors: French, George A., Castanho, Paul C., Swirsky, Carol A., Dunham, Leslie S.
• Application Number:
  US13/287,565
• Publication Number:
  US 20130110555A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Exemplary embodiments provide systems and methods that automatically gather, organize, present, and communicate data and information that aid a claim handler in making an accurate, informed decision regarding whether or not to allow or approve an authorization request, payment, claim, or action associated with a pharmacy insurance claim. Exemplary embodiments include a software application that reduces the effort required and increases the speed and effectiveness of claim handlers by providing organized, immediate access to claim summary and detailed pharmacy information, which streamlines reviews and the request approval process, including payment requests and prior authorization requests. Various embodiments also activate real-time alerts and reminders to claim handlers for various pharmacy claim management tasks.

Claims

1. A method, implemented using a computing system, for managing pharmacy insurance claims, the method comprising:

receiving a request to authorize an action associated with a pharmacy claim, wherein the request includes information identifying the pharmacy claim;

accessing, using the computing system, data corresponding to the pharmacy claim;

presenting to a user, using the computing system, the data corresponding to the pharmacy claim; and

enabling the user, using the computing system, to respond to the request to authorize the action.

2. The method of claim 1, wherein the request to authorize an action associated with the pharmacy claim comprises a request for a prior authorization approval to fill a prescription under the pharmacy claim.

3. The method of claim 1, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize payment of a pharmacy bill under the pharmacy claim.

4. The method of claim 1, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize a pharmacy evaluation service associated with the pharmacy claim.

5. The method of claim 1, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize a home delivery.

6. The method of claim 1, wherein presenting the data corresponding to the pharmacy claim comprises:

presenting the data on a graphical user interface that allows the user to display the data on a single screen.

7. The method of claim 1, wherein enabling the user to respond comprises:

placing the user in an external application program that accepts a response from the user.

8. The method of claim 7, further comprising:

receiving data confirming the response from the external application program; and

updating the data corresponding to the pharmacy claim to reflect the data confirming the response.

9. A system for managing pharmacy insurance claims comprising:

a memory containing instructions; and

a processor;

operably connected to the memory, that executes the instructions to perform operations comprising;

receiving a request to authorize an action associated with a pharmacy claim, wherein the request includes information identifying the pharmacy claim;

accessing data corresponding to the pharmacy claim;

presenting to a user the data corresponding to the pharmacy claim; and

enabling the user to respond to the request to authorize the action.

10. The system of claim 9, wherein the request to authorize an action associated with the pharmacy claim comprises a request for a prior authorization approval to fill a prescription under the pharmacy claim.

11. The system of claim 9, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize payment of a pharmacy bill under the pharmacy claim.

12. The system of claim 9, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize a pharmacy evaluation service associated with the pharmacy claim.

13. The system of claim 9, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize a home delivery.

14. The system of claim 9, wherein presenting the data corresponding to the pharmacy claim comprises:

presenting the data on a graphical user interface that allows the user to display the data on a single screen.

15. The system of claim 9, wherein enabling the user to respond comprises:

placing the user in an external application program that accepts a response from the user.

16. The system of claim 15, wherein the operations further comprise:

receiving data confirming the response from the external application program; and

updating the data corresponding to the pharmacy claim to reflect the data confirming the response.

17. A method, implemented using a computing system, for facilitating pharmacy insurance claims, the method comprising:

receiving, from a user, using the computer system, a request for an action, wherein the request is responsive to an electronic notification associated with a pharmacy claim;

opening a user interface in response to the request from the user;

displaying, in a first portion of the user interface, information identifying the pharmacy claim;

displaying, in a second portion of the user interface, information indicating a work status of a claimant for the pharmacy claim;

displaying, in a third portion of the user interface, a medication history for the pharmacy claim.

18. The method of claim 17, wherein displaying the medication history comprises:

displaying an indication of whether a prescription bill for a medication was approved for coverage or denied.

19. The method of claim 17, further comprising:

displaying, in a fourth portion of the user interface, a list of prescribers for the pharmacy claim;

wherein the fourth portion of the user interface may be co-located with the third portion of the user interface.

20. The method of claim 19, wherein displaying the list of prescribers comprises:

displaying an indication of whether each prescriber in the list was authorized or not authorized to prescribe medication under, the pharmacy claim.

21. The method of claim 17, further comprising:

displaying, in a fourth portion of the user interface, a list of alert messages that are relevant to the pharmacy claim;

wherein the fourth portion of the user interface may be co-located with the third portion of the user interface.

22. The method of claim 17, further comprising:

displaying, in a fourth portion of the user interface, a list of clinical services associated with the pharmacy claim;

wherein the fourth portion of the user interface may be co-located with the third portion of the user interface.

23. The method of claim 17, further comprising:

providing, to the user, the electronic notification associated with the pharmacy claim.

24. The method of claim 17, wherein the electronic notification relates to a request to authorize an action associated with the pharmacy claim.

25. The method of claim 24, wherein the request to authorize an action associated with the pharmacy claim comprises a request for a prior authorization approval to fill a prescription under the pharmacy claim.

26. The method of claim 24, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize payment of a pharmacy bill under the pharmacy claim.

27. The method of claim 24, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize a pharmacy evaluation service associated with the pharmacy claim.

28. The method of claim 24, wherein the request to authorize an action associated with the pharmacy claim comprises a request to authorize a home delivery.