Apparatus and method for managing prescription benefits

• US 7,155,397 B2
• Filed: 01/02/2003
• Issued: 12/26/2006
• Est. Priority Date: 01/22/2002
• Status: Expired due to Term

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Carlson, Mark A., Alexander, Jeffrey H., Stettin, Glen D., Jackson, William J., Healy, Richard P., Taylor, Nicholas C., Juravel, Zev
• Primary Examiner(s): GILLIGAN, CHRISTOPHER L
• Application Number:
  US10/334,981
• Publication Number:
  US 20040024614A1
• Time in Patent Office: 1,454 Days
• Field of Search: 705 2- 4, 707/3, 707/4, 707/104.1
• 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: 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 using a prescription benefit management system for a plurality of prescription benefit selections offered by at least one prescription benefit provider and administered by at least one prescription benefit administrator, the method comprising the steps:

conducting a search using said prescription benefit management system for a predetermined case record using a search parameter page generated by the prescription benefit management system responsive to a request by the prescription benefit administrator, the case record containing information regarding a patient and prescription coverage activities for the patient;

if multiple case records are retrieved from the search, then performing the steps;

selecting, by said prescription benefit administrator, a desired case record for review,

automatically capturing identification data from the selected case record by said prescription benefit management system,

conducting at least one subsequent case record specific search by said prescription benefit administrator, and

filtering the at least one subsequent case record specific search results with respect to the selected case record using the identification data by said prescription benefit management system;

accessing the case record, if a single case record is retrieved from the search;

conducting an inquiry on the case record to view or review selected prescription coverage activities contained in the case record;

inputting additional prescription coverage activities into the case record, if necessary;

verifying that the case record has been updated, if additional prescription coverage activities will not be inputted; and

closing the case record.

2. A system for managing prescription benefits using a prescription benefit management system for a plurality of prescription benefit selections offered by at least one prescription benefit provider and administered by at least one prescription benefit administrator, comprising:

a prescription benefits management system for a plurality of prescription benefit selections offered by at least one prescription benefit provider and administered by at least one prescription benefit administrator, storing case records containing information regarding 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 over one or more electronic communication networks; and

a user computer for accessing said prescription benefits management system from a remote location via said one or more electronic communication networks;

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

conduct searches for predetermined case records using a search parameter page generated by said prescription benefit management system,

if multiple case records are retrieved from the search, then performing the steps;

selecting a desired case record for review by said prescription benefit administrator,

automatically capturing identification data from said desired case record by said prescription benefit management system,

conducting at least one subsequent case record specific search by said prescription benefit administrator, and

filtering the at least one subsequent case record specific search results with respect to the selected case record using the identification data by said prescription benefit management system,

conduct an inquiry on said desired case record to view or review selected prescription coverage activities contained therein,

input additional prescription coverage activities into said desired case record, when the additional prescription coverage activities exist,

verify that said desired case record has been updated, when additional prescription coverage activities will not be inputted, and

close said desired case record.

3. A method of managing prescription benefits using a prescription benefit management system for a plurality of prescription benefit selections offered by at least one prescription benefit provider and administered by at least one prescription benefit administrator, the method, comprising the steps:

conducting a search for a predetermined case record using a search parameter page generated by the prescription benefit management system for a first user, the case record containing information regarding a patient and prescription coverage activities for the patient;

selecting, by said prescription benefit administrator, a desired case record for review from one or more case records retrieved by the search in response to receiving a user selection from the first user;

automatically capturing identification data from the selected case record by said prescription benefit management system;

conducting at least one subsequent case record specific search by said prescription benefit administrator,

filtering the at least one subsequent case record specific search results with respect to the selected case record using the captured identification data;

determining if the selected case record is currently being viewed by a second user;

determining prescribed access rights for the first user and the second user for accessing the selected case record;

releasing to the first user the selected case record from the second user without the second user'"'"'s authorization when the first user has the prescribed access rights, and preventing release of the selected case record to the first user when the first user does not have the prescribed rights;

conducting an inquiry on the selected case record to view or review selected prescription coverage activities contained therein;

inputting additional prescription coverage activities into the selected case record, if when the at least one of the fist and second user has prescribed access rights;

preventing input of additional prescription coverage activities into the selected case record when the at least one of the first and second user does not have prescribed access rights;

verifying that the selected case record has been updated, if additional prescription coverage activities will not be inputted; and

closing the selected case record.

4. The method of claim 3 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.

5. The method of claim 3, further comprising a step of displaying a status report identifying at least approvals/denials of claims for prescription coverage.

6. The method of claim 3, further comprising a step of viewing a reference library containing a collection of documents used to support decisions made on a case record.

7. The method of claim 3, 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.

8. The method of claim 3, 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.

9. The method of claim 3, 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.

10. The method of claim 3, further comprising a step of displaying an activity report containing all prescription coverage activities and reference data for the case record.

11. The method of claim 3, 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.

12. The method of claim 3, 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.

13. The method of claim 12, 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.

14. The method of claim 12, further comprising a step of processing appealing the coverage denial based on clinical reasons, and wherein the coverage denial may be reversed or upheld.

15. The method of claim 14, 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.

16. The method of claim 14, 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.

17. The method of claim 3, further comprising a step of creating a new review for the selected case record, and entering prescription coverage activity information for the case record.

18. The method of claim 3, 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 states; and

entering changes to one or more case parameters.

19. The method of claim 18, further comprising a step of generating correspondence to be sent to a patient identified in the case record.

20. The method of claim 3, further comprising a step of automatically generating status reports for one or more clients at predetermined intervals.

21. The method of claim 3, further comprising a step of automatically generating and maintaining a record of all transactions performed while using the prescription benefits management system.

22. A method of managing prescription benefits using a prescription benefit management system for a plurality of prescription benefit selections offered by at least one prescription benefit provider and administered by at least one prescription benefit administrator, the method, comprising the steps:

conducting a search for a predetermined case record using a search parameter page generated by the prescription benefit management system for a first user, the case record containing information regarding a patient and prescription coverage activities for the patient;

selecting, by said prescription benefit administrator, a desired case record for review from one or more case records retrieved by the search in response to receiving a user selection from the first user;

automatically capturing identification data from the selected case record by said prescription benefit management system;

conducting at least one subsequent case record specific search by said prescription benefit administrator;

filtering the at least one subsequent case record specific search results with respect to the selected case record using the captured identification data;

determining if the selected case record is currently being viewed by a second user;

determining prescribed access rights for the first user and the second user for accessing the selected case record;

releasing to the first user the selected case record from the second user without the second user'"'"'s authorization when the first user has the prescribed access rights, and preventing release of the selected case record to the first user when the first user does not have the prescribed rights;

conducting an inquiry on the selected case record to view or review selected prescription coverage activities contained therein;

inputting additional prescription coverage activities into the selected case record, if the current user has prescribed access rights;

preventing input of additional prescription coverage activities into the selected case record when the at least one of the first and second user does not have prescribed access rights;

verifying that the selected case record has been updated, when additional prescription coverage activities will not be inputted;

automatically generating status reports for one or more clients at predetermined intervals;

generating correspondence to be sent to a patient identified in the case record

creating a new review for the selected case record, and entering prescription coverage activity information for the case record;

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

entering changes to one or more case parameters;

displaying one or more reasons for each coverage denial, reviewing details of the displayed reasons, and overriding the displayed coverage denial based on one or more clinical criteria;

appealing at least one coverage denial based on clinical reasons in response to receiving a request from a user to at least one of appeal and override an initially correct prescription coverage denial based on additional information provided by the user, and wherein the coverage denial may be reversed or upheld, replacing an original prescription product with a substitute prescription product that is covered by a prescription benefit plan associated with the case record, and viewing entries generated by prior reviews of at least one of the case record and any coverage denials thereof; and

closing the selected case record.

23. A method of managing prescription benefits using a prescription benefit management system for a plurality of prescription benefit selections offered by at least one prescription benefit provider and administered by at least one prescription benefit administrator, the method, comprising the steps:

receiving at least one search term from a first user to search for a predetermined case record using a search parameter page generated by the prescription benefit management system, wherein the search parameter page includes an archive parameter;

determining whether to search through historical and current data based on the archive parameter;

conducting the search for the predetermined case record based at least in part on the at least one search term and the archive parameter;

generating a search results page that provides the user with multiple case records that match the at least one search term;

receiving an indication from the user to select a case record from the multiple case records;

automatically capturing identification data from the selected case record by said prescription benefit management system;

conducting at least one subsequent case record specific search by said prescription benefit administrator,

filtering the at least one subsequent case record specific search results with respect to the selected case record by using the captured identification data by said prescription benefit management system;

determining whether the use is a clinical user;

when the user is determined to be the clinical user, generating a report for the case record that includes one or more communications that have occurred for the case record, coverage criteria relating to a prescription benefit plan, and an activity summary that is user selectable;

in response to receiving an indication that the user has selected the activity summary, providing the user with a user-selectable list of approvals and denials of coverage, wherein the user-selectable list provides the user with an opportunity to override denials of coverage; and

in response to receiving an indication that the user has overridden the denial of coverage comprising an initially correct prescription coverage denial based on additional information provided by the user, automatically ordering a substitute prescription product that is covered by the prescription benefit plan that was previously denied to replace an original prescription product indicated in the case record.