System for pre-processing drug benefit claims according to processed drug lists
First Claim
1. A non-transitory computer-readable medium comprising instructions that when executed on at least one computer, cause the at least one computer to perform a method of sorting and processing drug claims, the method comprising:
- (a) receiving a claim using the at least one computer;
(b) sorting the claim for processing by;
(i) determining if the claim is for a drug listed as a home infusion drug, and if not, then;
(ii) determining if the claim is for a drug that is only listed as a Medicare Part B drug, and if not then;
(iii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and
if not then;
(iv) determining if the claim is for a drug that is listed as a required special class drug, and if not, then;
(v) determining if the claim is for a drug that is listed as a nebulized drug, and if not, then;
(vi) determining if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, and if not, then;
(vii) determining if the claim is for a drug that is listed as a Medicare statutorily excluded non-Part D drug, and if not, then;
(viii) determining if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, and if not, then;
(ix) determining whether the claim is for a drug that is listed as eligible for either Medicare Part D or Medicare Part D covered under an enhanced benefit system; and
if so, then determining whether the drug has been previously determined to be covered under the enhanced benefit system for the particular patient associated with the claim; and
(c) processing the claim as follows;
(i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim;
(ii) if the claim is for a drug that is only listed as a Medicare Part B drug, then processing the claim as a Medicare Part B drug claim;
(iii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim;
(iv) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim;
(vi) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim;
(vii) if the claim is for a drug that is listed as a required special class drug, then processing the claim as a required special class drug claim;
(viii) if the claim is for a drug that is listed as a nebulized drug, then processing the claim as a nebulized drug claim;
(ix) if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, then processing the claim as an over the counter drug claim under Medicare Part D;
(x) if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, then, then processing the claim under an enhanced benefit system under Medicare Part D;
(xi) if the claim is for a drug that is listed as a Medicare Part D drug that is covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim under an enhanced benefit system under Medicare Part D; and
(xii) if the claim is for a drug that is listed as a Medicare Part D drug that is not covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim as a standard Medicare Part D drug claim.
6 Assignments
0 Petitions
Accused Products
Abstract
A method of processing drug claims, by: (a) receiving a claim; (b) sorting the claim for processing by determining which processed drug list the claim belongs with; and then (c) processing the claim according to the particular processed drug list to which the claim belongs. A hierarchy of drug lists are used in a preferred order. If the drug is found on the first drug list, the system then moves directly to the processing stage. However, if the drug is not found on the first list, the system checks whether the drug is on the second drug list. If the drug is found on the second drug list, the system then moves directly to the processing stage, etc. Preferably, the drug list hierarchy is as follows: (i) home infusion drug list; (ii) drug only listed as a Medicare Part B drug list; (iii) drug listed as either Medicare Part B or D drug list; (iv) required special class drug list; (v) nebulized drug list; (vi) over the counter drug list; (vii) Medicare statutorily excluded non-Part D drug list; (viii) enhanced benefit system drug list; (ix) Medicare Part D or Medicare Part D covered under an enhanced benefit drug list, and (x) a vaccine drug list.
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Citations
34 Claims
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1. A non-transitory computer-readable medium comprising instructions that when executed on at least one computer, cause the at least one computer to perform a method of sorting and processing drug claims, the method comprising:
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(a) receiving a claim using the at least one computer; (b) sorting the claim for processing by; (i) determining if the claim is for a drug listed as a home infusion drug, and if not, then; (ii) determining if the claim is for a drug that is only listed as a Medicare Part B drug, and if not then; (iii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and
if not then;(iv) determining if the claim is for a drug that is listed as a required special class drug, and if not, then; (v) determining if the claim is for a drug that is listed as a nebulized drug, and if not, then; (vi) determining if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, and if not, then; (vii) determining if the claim is for a drug that is listed as a Medicare statutorily excluded non-Part D drug, and if not, then; (viii) determining if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, and if not, then; (ix) determining whether the claim is for a drug that is listed as eligible for either Medicare Part D or Medicare Part D covered under an enhanced benefit system; and
if so, then determining whether the drug has been previously determined to be covered under the enhanced benefit system for the particular patient associated with the claim; and(c) processing the claim as follows; (i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim; (ii) if the claim is for a drug that is only listed as a Medicare Part B drug, then processing the claim as a Medicare Part B drug claim; (iii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim; (iv) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim; (vi) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim; (vii) if the claim is for a drug that is listed as a required special class drug, then processing the claim as a required special class drug claim; (viii) if the claim is for a drug that is listed as a nebulized drug, then processing the claim as a nebulized drug claim; (ix) if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, then processing the claim as an over the counter drug claim under Medicare Part D; (x) if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, then, then processing the claim under an enhanced benefit system under Medicare Part D; (xi) if the claim is for a drug that is listed as a Medicare Part D drug that is covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim under an enhanced benefit system under Medicare Part D; and (xii) if the claim is for a drug that is listed as a Medicare Part D drug that is not covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim as a standard Medicare Part D drug claim. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20)
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21. A computerized system for sorting and processing drug claims, comprising:
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(a) a computer for receiving a claim; (b) a system for sorting the claim for processing by; (i) determining if the claim is for a drug listed as a home infusion drug, and if not, then; (ii) determining if the claim is for a drug that is only listed as a Medicare Part B drug, and if not then; (iii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and
if not then,(iv) determining if the claim is for a drug that is listed as a required special class drug, and if not, then; (v) determining if the claim is for a drug that is listed as a nebulized drug, and if not, then; (vi) determining if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, and if not, then; (vii) determining if the claim is for a drug that is listed as a Medicare statutorily excluded non-Part D drug, and if not, then; (viii) determining if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, and if not, then; (ix) determining whether the claim is for a drug that is listed as eligible for either Medicare Part D or Medicare Part D covered under an enhanced benefit system; and
if so, then determining whether the drug has been previously determined to be covered under an enhanced benefit system for the particular patient associated with the claim; and(c) a system for processing the claim as follows; (i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim; (ii) if the claim is for a drug that is only listed as a Medicare Part B drug, then processing the claim as a Medicare Part B drug claim; (iii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim; (iv) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim; (vi) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim; (vii) if the claim is for a drug that is listed as a required special class drug, then processing the claim as a required special class drug claim; (viii) if the claim is for a drug that is listed as a nebulized drug, then processing the claim as a nebulized drug claim; (ix) if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, then processing the claim as an over the counter drug claim under Medicare Part D; (x) if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, then, then processing the claim under an enhanced benefit system under Medicare Part D; (xi) if the claim is for a drug that is listed as a Medicare Part D drug that is covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim under an enhanced benefit system under Medicare Part D; and (xii) if the claim is for a drug that is listed as a Medicare Part D drug that is not covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim as a standard Medicare Part D drug claim.
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22. A non-transitory computer-readable medium comprising instructions that when executed on at least one computer, cause the at least one computer to perform a method of sorting and processing drug claims, the method comprising:
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(a) receiving a claim using a computer; (b) sorting the claim for processing by; (i) determining if the claim is for a home infusion drug, and if not then; (ii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining by a formulary or representative drug code approach whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and (c) processing the claim as follows; (i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim; (ii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim; (iii) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim, and (iv) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim. - View Dependent Claims (23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33)
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34. A computerized system for sorting and processing drug claims, comprising:
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(a) a computer for receiving a claim; (b) a system for sorting the claim for processing by; (i) determining if the claim is for a home infusion drug, and if not then; (ii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining by a formulary-specific representative drug code approach whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and (c) a system for processing the claim as follows; (i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim; (ii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim; (iii) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim; and (iv) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim.
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Specification