Systems and methods for verifying and editing electronically transmitted claim content

• US 8,190,453 B2
• Filed: 05/16/2003
• Issued: 05/29/2012
• Est. Priority Date: 05/16/2002
• Status: Active Grant

• Current Assignee: NDCHealth Corp. (McKesson Corp.)
• Original Assignee: NDCHealth Corp. (McKesson Corp.)
• Inventors: Rowe, James Couser III, Pinsonneault, Roger G.
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): PASS, NATALIE
• Application Number:
  US10/439,422
• Publication Number:
  US 20040078247A1
• Time in Patent Office: 3,301 Days
• Field of Search: 705/1, 705/36, 705/38, 705/40, 705/26, 705/14, 705/51, 705/42, 705/44, 705 2- 4, 715/531, 715/530, 707/102, 707/100, 707/104.1, 707/10
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/4016 involving fraud or risk level assessment in transaction processing
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

Systems and methods verify the content of an electronically transmitted claim, such as a healthcare claim by intercepting the claim, reviewing the claim'"'"'s contents, and comparing the claim to pre-established claim criteria established by a payer or both a healthcare service provider and payer. If the claim contains the appropriate content the claim is forwarded to its intended recipient, typically a payer such as an insurance company or government healthcare payer; otherwise the claim may be returned to the sender, e.g., a pharmacy, with an indication that it does not contain the correct content. Additionally, the claim may be edited by the system and forwarded in correct form to its intended recipient.

Claims

1. A method for providing real time or near real time editing of prescription claim content prior to adjudication of a prescription claim, comprising:

storing a plurality of pre-established prescription claim criteria associated with a payer system in memory, wherein the plurality of pre-established prescription claim criteria includes criteria previously submitted by the payer system to a host server computer system;

receiving, at the host server computer system, a prescription claim from a pharmacy point-of-service (POS) device, wherein the prescription claim includes a plurality of prescription claim contents and wherein a portion of the prescription claim contents indicates that the prescription claim is directed to the payer;

accessing, from the memory, the plurality of pre-established prescription claim criteria associated with the payer system;

comparing, by the host server computer system, at least one of plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the payer system;

determining, based on the comparison of at least one of the plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the payer system, that at least one of plurality of prescription claim contents should be compared to objective information accessible by the host server computer system and provided by at least one party other than the pharmacy associated with the pharmacy POS device or the payer;

comparing, by the host server computer system, at least one of the plurality of prescription claim contents to the objective information;

editing, by the host server computer system, at least one of the plurality of prescription claim contents in the prescription claim based on the comparison of at least one of the plurality of prescription claim contents to the objective information, wherein the editing modifies at least one of the plurality of prescription claim contents creating an edited prescription claim; and

transmitting the edited prescription claim to the payer for subsequent adjudication.

2. The method of claim 1, further comprising forwarding a message to the pharmacy POS device, wherein the message includes an indication that the prescription claim did not contain the correct prescription claim contents.

3. The method of claim 1, wherein the objective information includes historical consumer claim information.

4. The method of claim 1, wherein the host server computer system is in electrical communication with the payer system via the Internet.

5. The method of claim 1, further comprising storing at least one of the plurality of prescription claim contents prior to the editing.

6. The method of claim 1, further comprising storing at least one of the edited prescription claim contents after the editing.

7. The method of claim 1, wherein the prescription claim includes data associated with filling a prescription or requesting approval for payment from the payer system.

8. The method of claim 1, wherein editing at least one of the plurality of prescription claim contents in the prescription claim based on the comparison of at least one of the plurality of prescription claim contents to the objective information includes adding additional prescription claim content to the prescription claim.

9. The method claim 1, wherein the plurality of pre-established prescription claim criteria comprises at least one of physician information, payer information, drug information, drug price information, or drug dosage information.

10. The method of claim 1, further comprising:

prior to transmitting the edited prescription claim to the payer for subsequent adjudication;

accessing, from the memory, a plurality of pre-established prescription claim criteria associated with the pharmacy provider;

comparing, by the host server computer system, at least one of plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the pharmacy provider; and

editing at least one of the plurality of prescription claim contents in the prescription claim based on the comparison of at least one of the plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the pharmacy provider.

11. A system for providing real time or near real time editing of prescription claim content prior to adjudication of a prescription claim, comprising:

at least one database, wherein the at least one database stores a plurality of pre-established prescription claim criteria associated with a payer system in the at least one database;

a host server computer system in communication with the at least one database, wherein the plurality of pre-established prescription claim criteria includes criteria previously submitted by the payer system to the host server computer system, and wherein the host server computer system is configured to execute instructions to;

receive a prescription claim from a pharmacy point-of-service (POS) device, wherein the prescription claim includes a plurality of prescription claim contents and wherein a portion of the prescription claim contents indicates that the prescription claim is directed to the payer;

access, from the at least one database, the plurality of pre-established prescription claim criteria associated with the payer system;

compare at least one of plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the payer system;

determine, based on the comparison of at least one of the plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the payer system, that at least one of plurality of prescription claim contents should be compared to objective information accessible by the host server computer system and provided by at least one party other than the pharmacy associated with the pharmacy POS;

compare at least one of the plurality of prescription claim contents to the objective information;

edit at least one of the plurality of prescription claim contents in the prescription claim based on the comparison of at least one of the plurality of prescription claim contents to the objective information, wherein the editing modifies at least one of the plurality of prescription claim contents creating an edited prescription claim; and

transmit the edited prescription claim to the payer for subsequent adjudication.

12. The system of claim 11, wherein the host server computer system is further configured to execute instructions to forward a message to the pharmacy POS device, wherein the message includes an indication that the prescription claim did not contain the correct prescription claim contents.

13. The system of claim 11, wherein the objective information includes historical consumer claim information.

14. The system of claim 11, wherein the host server computer system is in electrical communication with the payer system via the Internet.

15. The system of claim 11, wherein the host server computer system is further configured to execute instructions to store at least one of the plurality of prescription claim contents prior to the editing.

16. The system of claim 11, wherein the host server computer system is further configured to execute instructions to store at least one of the edited prescription claim contents after the editing.

17. The system of claim 11, wherein the prescription claim includes data associated with filling a prescription or requesting approval for payment from the payer system.

18. The system of claim 11, wherein the instructions to edit at least one of the plurality of prescription claim contents in said prescription claim based on the comparison of at least one of the plurality of prescription claim contents to the objective information include instructions to add additional prescription claim content to the prescription claim.

19. The system claim 11, wherein the plurality of pre-established prescription claim criteria includes at least one of physician information, payer information, drug information, drug price information, or drug dosage information.

20. The system of claim 11, wherein the host server computer system is further configured to execute instructions to:

prior to transmitting the edited prescription claim to the payer for subsequent adjudication;

access, from the at least one database, a plurality of pre-established prescription claim criteria associated with the pharmacy provider;

compare at least one of plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the pharmacy provider; and

edit at least one of the plurality of prescription claim contents in said prescription claim based on the comparison of at least one of the plurality of prescription claim contents to the plurality of pre-established prescription claim criteria associated with the pharmacy provider.