Systems and methods for the intelligent coordination of benefits in healthcare transactions

• US 8,321,243 B1
• Filed: 02/15/2010
• Issued: 11/27/2012
• Est. Priority Date: 02/15/2010
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: Mckesson Financial Holdings Limited (McKesson Corp.)
• Inventors: Harris, Patrick Sr., Pinsonneault, Roger
• Primary Examiner(s): PAULS, JOHN A
• Application Number:
  US12/705,921
• Time in Patent Office: 1,016 Days
• Field of Search: 705/2, 705/3, 705/4
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients

Abstract

Systems and methods are provided for the coordination of benefits. The systems and methods may include receiving a healthcare claim request from a healthcare provider computer; determining, based at least in part from patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer; generating a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer; and generating a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply associated with the primary claim request, the COB claim request, the COB claim request associated with a second payer.

Claims

1. A computer-implemented method, comprising:

receiving a healthcare claim request from a healthcare provider computer, the healthcare claim request including patient information identifying a patient, and product information identifying a product for the patient;

determining, based at least in part from a portion of the patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer, wherein the determining includes;

transmitting an eligibility request to an eligibility verification computer, the eligibility request including at least a portion of the patient information in the healthcare transaction claim request, and

receiving, from the eligibility verification computer, an eligibility reply that identifies at least two payers associated with the patient, wherein the eligibility reply includes respective cardholder identifiers for the at least two payers, wherein the cardholder identifiers identify the account holder for each respective payer, wherein the cardholder identifiers are different for each respective payer,

wherein the respective cardholder identifiers for the at least two payers are utilized to determine which of the at least two payers is the first payer or the second payer;

generating a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer;

communicating the generated primary claim request to a first claims processor computer associated with the first payer for adjudication;

receiving, from the first claims processor computer, a first adjudicated reply for the primary claim, the first adjudicated reply indicating first financial coverage information for the identified product for the patient;

generating a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply, the COB claim request including at least a portion of the first financial coverage information for the identified product, the COB claim request associated with a second payer;

communicating the generated COB claim request to a second claims processor computer associated with the second payer for adjudication;

receiving, from the second claims processor computer, a second adjudicated reply for the COB claim; and

communicating information associated with the first adjudicated reply and the second adjudicated reply to the healthcare provider computer,

wherein the above operations are performed by one or more computers associated with a service provider.

2. The computer-implemented method of claim 1, further comprising:

ordering the respective at least two payers in a sequence; and

identifying the first and second payers from the at least two payers according to the sequence,

wherein the above operations are performed by one or more computers associated with the service provider.

3. The computer-implemented method of claim 1, wherein the patient is determined to be associated with the first payer, the second payer, and a third payer, wherein the coordination of benefits (COB) claim request is a first COB claim request, wherein the second adjudicated reply indicates second financial coverage information for the identified product for the patient, and further comprising:

generating a second coordination of benefits (COB) claim request based at least in part on one or both of the received first adjudicated reply or the second adjudicated reply, the second COB claim request including at least a portion of one or both of the first or second financial coverage information, the second COB claim request associated with a third payer;

communicating the generated second COB claim request to a third claims processor computer associated with the third payer for adjudication;

receiving, from the third claims processor computer, a third adjudicated reply for the second COB claim;

aggregating at least a portion of the first adjudicated reply, the second adjudicated reply, and the third adjudicated reply into a single response for the healthcare claim request; and

communicating the single response to the healthcare provider computer,

wherein the above operations are performed by one or more computers associated with the service provider.

4. The computer-implemented method of claim 1, further comprising:

aggregating at least a portion of the first adjudicated reply and the second adjudicated reply into a single response for the healthcare claim request,

wherein communicating information associated with the first adjudicated reply and the second adjudicated reply to the healthcare provider computer comprises communicating the single response to the healthcare provider computer,

wherein the above operations are performed by one or more computers associated with the service provider.

5. The computer-implemented method of claim 1, wherein receiving a first adjudicated reply comprises receiving a first adjudicated reply indicating that the primary claim request has been approved by the first claims processor computer, and further comprising:

identifying an amount paid based upon the first financial coverage information for the first adjudicated reply; and

determining a second payment amount based at least in part on the identified amount paid for the first adjudicated reply,

wherein generating the COB claim request comprises generating the COB claim request utilizing the determined second payment amount,

wherein the above operations are performed by one or more computers associated with the service provider.

6. The computer-implemented method of claim 5, wherein determining a second payment amount comprises determining one of a secondary insurance payment amount or a patient responsibility amount.

7. The computer-implemented method of claim 1, wherein:

receiving a first adjudicated reply comprises receiving a first adjudicated reply indicating that the primary claim request has been rejected by the first claims processor computer, wherein the first financial coverage indicates no coverage by the primary payer, and

generating a coordination of benefits (COB) claim request comprises generating the COB claim request utilizing at least a portion of the data included in the rejected primary claim request.

8. The computer-implemented method of claim 7, wherein receiving a second adjudicated reply comprises receiving a second adjudicated reply indicating that the COB claim request has been denied by the second claims processor computer, and further comprising:

determining a reject code associated with the denial of the COB claim request, wherein the above operation is performed by one or more computers associated with the service provider.

9. The computer-implemented method of claim 8, further comprising:

determining that the patient is not associated with any other payer other than the first payer and the second payer;

based upon the determination that the patent is not associated with any other payer, identifying the healthcare claim request as a denied healthcare claim request,

wherein the above operations are performed by one or more computers associated with the service provider.

10. A system, comprising:

at least one memory operable to store computer-executable instructions; and

at least one processor configured to access the at least one memory and execute the computer-executable instructions to;

receive a healthcare claim request from a healthcare provider computer, the healthcare claim request including patient information identifying a patient, and product information identifying a product for the patient;

determine, based at least in part from a portion of the patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer by,

transmitting an eligibility request to an eligibility verification computer, the eligibility request including at least a portion of the patient information in the healthcare transaction claim request, and

receiving, from the eligibility verification computer, an eligibility reply that identifies at least two payers associated with the patient,

wherein the eligibility reply includes respective cardholder identifiers for the at least two payers, wherein the cardholder identifiers identify the account holder for each respective payer, wherein the cardholder identifiers are different for each respective payer, and wherein the respective cardholder identifiers for the at least two payers are utilized to determine which of the at least two payers is the first payer or the second payer;

generate a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer;

communicate the generated primary claim request to a first claims processor computer associated with the first payer for adjudication;

receive, from the first claims processor computer, a first adjudicated reply for the primary claim, the first adjudicated reply indicating first financial coverage information for the identified product for the patient;

generate a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply, the COB claim request including at least a portion of the first financial coverage information for the identified product, the COB claim request associated with a second payer;

communicate the generated COB claim request to a second claims processor computer associated with the second payer for adjudication;

receive, from the second claims processor computer, a second adjudicated reply for the COB claim; and

communicate information associated with the first adjudicated reply and the second adjudicated reply to the healthcare provider computer.

11. The system of claim 10, wherein the patient is determined to be associated with the first payer, the second payer, and a third payer, wherein the coordination of benefits (COB) claim request is a first COB claim request, wherein the second adjudicated reply indicates second financial coverage information for the identified product for the patient, and wherein the at least one processor is further configured to execute the computer-executable instructions to:

generate a second coordination of benefits (COB) claim request based at least in part on one or both of the received first adjudicated reply or the second adjudicated reply, the second COB claim request including at least a portion of one or both of the first or second financial coverage information, the second COB claim request associated with a third payer;

communicate the generated second COB claim request to a third claims processor computer associated with the third payer for adjudication;

receive, from the third claims processor computer, a third adjudicated reply for the second COB claim,

aggregate at least a portion of the first adjudicated reply, the second adjudicated reply, and the third adjudicated reply into a single response for the healthcare claim request; and

communicating the single response to the healthcare provider computer.

12. The system of claim 10, wherein the at least one processor is further configured to execute the computer-executable instructions to:

aggregate at least a portion of the first adjudicated reply and the second adjudicated reply into a single response for the healthcare claim request,

wherein the information associated with the first adjudicated reply and the second adjudicated reply is communicated to the healthcare provider computer by communicating the single response to the healthcare provider computer.

13. The system of claim 10, wherein receiving a first adjudicated reply comprises receiving a first adjudicated reply indicating that the primary claim request has been approved by the first claims processor computer, and wherein the at least one processor is further configured to execute the computer-executable instructions to:

identify an amount paid based upon the first financial coverage information for the first adjudicated reply; and

determine a second payment amount based at least in part on the identified amount paid for the first adjudicated reply,

wherein the COB claim request is generated utilizing the determined second payment amount.