Apparatus and method for managing prescription benefits

• US 7,774,213 B2
• Filed: 12/07/2006
• Issued: 08/10/2010
• Est. Priority Date: 01/22/2002
• Status: Expired due to Fees

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Alexander, Jeffrey H., Stettin, Glen D., Jackson, William J., Healy, Richard P., Carlson, Mark A., Taylor, Nicholas C., Juravel, Zev
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): NGUYEN, HIEP VAN
• Application Number:
  US11/635,714
• Publication Number:
  US 20070082543A1
• Time in Patent Office: 1,342 Days
• Field of Search: 705/2, 705/3, 705/4
• 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 offered by a plurality of providers of prescription benefits, comprising:

storing prescription benefit case records in a prescription benefits management computer system for users at least one of receiving or administrating one of a plurality of prescription benefits coverage plans from at least one of the plurality of providers of prescription benefits, said prescription benefit case records comprising information regarding patients and prescription coverage activities including at least one of a type of treatment associated with the prescription benefits coverage, pharmaceutical product used by the patient when present, and a number and type of communications with the patient associated with the prescription benefits coverage, accessible to the users responsive to the one of the plurality of prescription benefits coverage plans;

providing access to the plurality of prescription benefits coverage plans from the at least one of the plurality of providers of prescription benefits using said prescription benefits management computer system to respective plurality of providers of prescription benefits over one or more electronic communication networks;

receiving a request to access said prescription benefits management computer system from the user of at least one of the plurality of providers of prescription benefits from remote locations via one or more electronic communication networks, wherein access to said prescription benefits management computer system is provided based on at least one of a plurality of preconfigured access right corresponding to at least one of the user and the provider of the prescription benefits offered through the one of the plurality of prescription benefits coverage plans from the at least one the plurality of providers of prescription benefits;

selecting at least one of a plurality of prescription coverage activities contained in said prescription benefit case records corresponding to the prescription benefits coverage plan;

conducting an inquiry on said prescription benefit case records to view and reviewing selected prescription coverage activities contained in said prescription benefit case records responsive to the request from the user, wherein the inquiry to view and review the selected prescription coverage activities further comprises displaying a plurality of options to access said prescription coverage activities for the user based on the at least one of a plurality of preconfigured access rights, and selecting at least one of the plurality of options to access said prescription coverage activities,

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 the user,

selecting a new prescription benefit case record for prescription benefits,

determining whether the new case record is currently being viewed by a second user,

receiving instructions from user to release the new case record if the new case record is currently being viewed by the second user,

determining whether the user is an employee of at least one organization, offering the one of the plurality of prescription benefits coverage plans from the at least one of the plurality of providers of prescription benefits, implementing the prescription benefits management computer system,

releasing the new prescription case record without the second user'"'"'s authorization if the second user is at least one of an employee and a client of the organization implementing the prescription benefits management computer system,

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 computer 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 computer system.

20. The method of claim 1, further comprising providing the user access to said prescription benefits management computer system based on authority to at least one of:

view, change, modify, and create information stored in the prescription benefits management computer system.

21. The method of claim 1,

wherein the preconfigured access rights comprises authority for an administrative user of the at least one of the plurality of providers of the prescription benefits, and

wherein said method further comprises providing access to the administrative user of the at least one of the plurality of providers of the prescription benefits to change, modify, and create information stored in the prescription benefits management computer system.

22. The method of claim 21,

wherein the preconfigured access rights comprises authority for a staff member of the prescription benefits management computer system, and

wherein said method further comprises providing access to the staff member to view, change, and modify information stored in the prescription benefits management computer system.

23. The method of claim 1, further comprising:

providing the at least one of the plurality of prescription benefits providers authority to view information stored in the prescription benefits management computer system, and

providing the at least one of the plurality of prescription benefits providers authority to respond to questions, and

providing the at least one of the plurality of prescription benefits providers authority to enter information into forms for storing in the prescription benefits management computer system.

24. The method of claim 1,

wherein the preconfigured access rights comprises authority for an administrative user of the at least one of the plurality of providers of the prescription benefits, and

wherein said method further comprises providing access to the administrative user to modify at least one of the plurality of case records of a member of the at least one of the plurality of providers of the prescription benefits stored in said prescription management computer system without the at least one user of the at least one of the plurality of providers releasing the at least one of the case records.

25. The method of claim 1,

wherein the preconfigured access rights comprises authority for an administrative user of the at least one of the plurality of providers of the prescription benefits, and

wherein said method further comprises providing access to the administrative user to release at least one of the plurality of case records of a member of the at least one of the plurality of providers of the prescription benefits stored in said prescription management computer system held open by the at least one user of the at least one of the plurality of providers.

26. The method of claim 1,

wherein the preconfigured access rights comprises authority for an administrative user of the at least one of the plurality of providers of the prescription benefits, and

wherein said method further comprises providing access to the administrative user to modify coverage criteria information, wherein the coverage criteria information comprises a decision regarding coverage for at least one of a product and treatment.

27. The method of claim 1, further comprising displaying the activity report for a case record comprising user identifier, carrier information, contract information, physician, patient, member, coverage criteria, and reasons for denial.

28. The method of claim 1, further comprising:

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

conducting a search for the at least one predetermined case record using the search parameter page generated by the prescription benefit management computer system for the user.

29. The method of claim 28, further comprising upon retrieving multiple case records from the search:

selecting at least one desired case record for review by said prescription benefit administrator,

automatically capturing identification data from the at least one desired case record by said prescription benefit management computer 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 at least one selected case record using the identification data by said prescription benefit management computer system.

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

a prescription benefits management computer system, for storing prescription benefit case records for patients receiving one of a plurality of prescription benefits coverage for the plurality of providers of prescription benefits, said prescription benefit case records comprising information regarding the patients and prescription coverage activities including at least one of a type of treatment associated with the prescription benefits coverage, pharmaceutical product used by the patient when present, and a number and type of communications with the patient associated with the prescription benefits coverage, pharmaceutical product used by the patient when present, and a number and type of communications with the patient associated with the prescription benefits coverage, accessible to the patient responsive to the one of the plurality of prescription benefits coverage plans;

a communication device operatively coupled to said prescription benefits management computer system for providing access to the plurality of prescription benefits coverage plans from the at least one of the plurality of providers of prescription benefits using said prescription benefits management computer system to respective plurality of providers of prescription benefits over one or more electronic communication networks; and

said prescription benefits management computer system for receiving a request to access said prescription benefits management computer system from a user of at least one of the plurality of providers of prescription benefits utilizing at least one user computer from remote locations via said one or more electronic communication networks, wherein access to said prescription benefits management computer system is provided based on at least one of a plurality of preconfigured access right corresponding to at least one of the user and the provider of the prescription benefits offered through the one of the plurality of prescription benefits coverage plans from the at least one of the plurality of providers of prescription benefits;

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

select at least one of a plurality of prescription coverage activities contained in said prescription benefit case records corresponding to the prescription benefits coverage plan;

conduct an inquiry on said prescription benefit case records to view and review selected prescription coverage activities contained in said prescription benefit case records responsive to the request from the user, wherein the inquiry to view and review the selected prescription coverage activities further comprises displaying a plurality of options to access said prescription coverage activities for the patient based on the at least one of a plurality of preconfigured access right, and selecting at least one of the plurality of options to access said prescription coverage activities,

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,

select a new prescription benefit case record for prescription benefits,

determine whether the new case record is currently being viewed by a second user,

receive instructions from user to release the new case record if the new case record is currently being viewed by the second user,

determine whether the user is an employee of at least one organization, offering the one of the plurality of prescription benefits coverage plans from the at least one of the plurality of providers of prescription benefits, implementing the prescription benefits management computer system,

release the new prescription case record without the second user'"'"'s authorization if the second user is at least one of an employee and a client of the organization implementing the prescription benefits management computer system,

modify information contained in the prescription benefit case record, and

close said prescription benefit case records.

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

storing prescription benefit case records in at least a prescription benefits management computer system for users receiving and/or administrating one of a plurality of prescription benefits coverage-plans from at least one of the plurality of providers of prescription benefits, said prescription benefit case records comprising at least information regarding at least one patient and prescription coverage activities including at least one of a type of treatment associated with the prescription benefits coverage, pharmaceutical product used by the patient when present, and a number and type of communication with the patient associated with the prescription benefits coverage, accessible to the users response to the one of the plurality of prescription benefits coverage plans;

providing access to the plurality of prescription benefits coverage plans from the at least one of the plurality of providers of prescription benefits using said prescription benefits management computer system to respective plurality of providers of prescription benefits over one or more electronic communication networks;

receiving a request to access said prescription benefits management computer system from a user of at least one of the plurality of providers of prescription benefits from remote locations via one or more electronic communication networks, wherein access to said prescription benefits management computer system is provided based on at least one of a plurality of preconfigured access right corresponding to at least one of the user and the provider of the prescription benefits offered through the one of the plurality of prescription benefits coverage plans from the at least one of the plurality of providers of prescription benefits;

selecting at least one of a plurality of prescription coverage activities contained in said prescription benefit case records corresponding to the prescription benefits coverage plan;

conducting an inquiry on said prescription benefit case records to view and reviewing selected prescription coverage activities contained in said prescription benefit case records responsive to the request from the user, wherein the inquiry to view and review the selected prescription coverage activities further comprises displaying a plurality of options to access said prescription coverage activities for the at least one patient based on the at least one of a plurality of preconfigured access rights, and selecting at least one of the plurality of options to access said prescription coverage activities,

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 the user,

selecting a new prescription benefit case record for prescription benefits,

determining whether the new case record is currently being viewed by a second user,

releasing the new prescription case record without the second user'"'"'s authorization when the user is determined to be the a clinical user,

modifying information contained in the prescription benefit case record, and

closing said prescription benefit case records.