Prescription creation and adjudication method

• US 8,099,295 B2
• Filed: 02/04/2003
• Issued: 01/17/2012
• Est. Priority Date: 02/04/2003
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Express Scripts Incorporated (The Cigna Group)
• Inventors: Virdee, Pritpal S., Wingate, Elizabeth S., Stuart, Mike, Rey-Giraud, Agnès
• Primary Examiner(s): Sereboff, Neal
• Application Number:
  US10/357,917
• Publication Number:
  US 20040153336A1
• Time in Patent Office: 3,269 Days
• Field of Search: 705/4, 705/2, 705/3
• 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 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients

Abstract

The invention provides a computer-implemented method for creating a prescription for treatment of an injury or illness covered by a workers'"'"' compensation system, which facilitates on-line adjudication of a workers'"'"' compensation claim. The patient name, employer name and type and quantity of medication prescribed are input. Routing data including a processor identification number is retrieved from an employer database. The program outputs prescription data comprising the name of the patient, the type and quantity of medication prescribed, and the routing data. The prescription data is preferably NCPDP compliant and used by a pharmacy to route a workers'"'"' compensation claim and fill the prescription.

Claims

1. A method comprising:

receiving, on a computer processor, a point of care identifier;

verifying, on the computer processor, a point of care location based on receipt of the point of care identifier;

receiving, on the computer processor, a received patient identifier and a medication identifier associated with a patient from a point of care transmission device, the point of care transmission device associated with the point of care location, the patient receiving medical treatment from a medical professional associated with the point of care location, the patient associated with an employer;

accessing, on the computer processor, patient data based on the received patient identifier;

accessing, on the computer processor, eligibility data from a database;

determining, on the computer processor, that the employer is among a plurality of eligible employers based on the eligibility data to identify the employer as being on-line claim adjudication eligible;

accessing, on the computer processor, employer data associated with the employer based on identification that the employer is on-line claim adjudication eligible, the employer data including routing data and worker compensation carrier data, the routing data including data to facilitate electronic adjudication of a prescription claim, the worker compensation carrier data including data identifying a worker compensation carrier associated with the employer;

receiving, on the computer processor, injury data associated with the patient, the injury data associated with an injury and an injury date that the injury occurred;

determining, on the computer processor, whether the injury falls within coverage provided by the worker compensation carrier to the employer;

assigning, on the computer processor, a claim identifier to the injury based on a determination that the injury falls within the coverage;

accessing, on the computer processor, medication data associated with medication to treat the injury based on the medication identifier, the medication data including a medication type of a medication and a medication quantity of the medication;

transmitting to the point of care transmission device network display generation data, the point of care transmission device being capable of generating a display of network pharmacies associated with a pharmacy benefit manager (PBM) based on receipt of the network display generation data, the PBM being associated with the employer;

receiving, on the computer processor, a network pharmacy selection based on transmission of network display generation data generation to the point of care transmission device;

generating, on the computer processor, a prescription for the medication, the prescription including the claim identifier, a transmittable patient identifier associated with the patient, the medication type, the medication quantity; and

transmitting, on the computer processor, the prescription over an electronic network to a pharmacy device based on receipt of the network pharmacy selection.

2. The method of claim 1, wherein the employer data further includes coverage data and determining whether the injury falls within coverage comprises:

determining, on the computer processor, whether the injury falls within coverage provided by the worker compensation carrier to the employer based on the coverage data.

3. The method of claim 1, further comprising:

receiving a preferred pharmacy selection of a preferred pharmacy from the point of care transmission device;

identifying a plurality of pharmacies located within a prescribed distance from the preferred pharmacy; and

generating the network display generation data based on identification of the plurality of pharmacies.

4. The method of claim 1, wherein the point of care identifier is received from the point of care transmission device.

5. The method of claim 1, wherein the transmittable patient identifier is the same identifier as the received patient identifier.

6. The method of claim 1, wherein the received patient identifier includes a patient name of the patient, a date of birth of the patient, a social security number of the patient, a phone number of the patient, or combinations thereof.

7. The method of claim 1, wherein the prescription further includes at least a portion of the employer data.

8. The method of claim 1, wherein the computer processor is deployed within a hand-held computing device at the point of care location.

9. The method of claim 1, wherein the point of care location includes a doctor'"'"'s office.

10. A non-transitory computer readable medium comprising instructions, which when implemented by one or more processors perform the following operations:

receive a point of care identifier;

verify a point of care location based on receipt of the point of care identifier;

receive a received patient identifier and a medication identifier associated with a patient from a point of care transmission device, the point of care transmission device associated with the point of care location, the patient receiving medical treatment from a medical professional associated with the point of care location, the patient associated with an employer;

access patient data based on the received patient identifier;

access eligibility data from a database;

determine that the employer is among a plurality of eligible employers based on the eligibility data to identify the employer as being on-line claim adjudication eligible;

access employer data associated with the employer based on identification that the employer is on-line claim adjudication eligible, the employer data including routing data and worker compensation carrier data, the routing data including data to facilitate electronic adjudication of a prescription claim, the worker compensation carrier data including data identifying a worker compensation carrier associated with the employer;

receive injury data associated with the patient, the injury data associated with an injury and an injury date that the injury occurred;

determine whether the injury falls within coverage provided by the worker compensation carrier to the employer;

assign a claim identifier to the injury based on a determination that the injury falls within the coverage;

access medication data associated with medication to treat the injury based on the medication identifier, the medication data including a medication type of a medication and a medication quantity of the medication;

transmit to the point of care transmission device network display generation data, the point of care transmission device being capable of generating a display of network pharmacies associated with a pharmacy benefit manager (PBM) based on receipt of the network display generation data, the PBM being associated with the employer;

receive a network pharmacy selection based on transmission of network display generation data generation to the point of care transmission device;

generate a prescription for the medication, the prescription including the claim identifier, a transmittable patient identifier associated with the patient, the medication type, the medication quantity; and

transmit the prescription over an electronic network to a pharmacy device based on receipt of the network pharmacy selection.