×

System for pre-processing drug benefit claims according to processed drug lists

  • US 8,265,950 B2
  • Filed: 12/18/2008
  • Issued: 09/11/2012
  • Est. Priority Date: 12/18/2008
  • Status: Active Grant
First Claim
Patent Images

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.

View all claims
  • 6 Assignments
Timeline View
Assignment View
    ×
    ×