Systems and methods for the identification of available payers for healthcare transactions

• US 8,335,672 B1
• Filed: 03/26/2010
• Issued: 12/18/2012
• Est. Priority Date: 03/26/2010
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: Mckesson Financial Holdings Limited (McKesson Corp.)
• Inventors: Ringold, James Morgan
• Primary Examiner(s): Lubin, Valerie
• Assistant Examiner(s): Reyes, Reginald R
• Application Number:
  US12/732,770
• Time in Patent Office: 998 Days
• Field of Search: 705 2- 3
• US Class Current: 703/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

Systems and methods are provided for the identification of available payers for healthcare transactions. A reply to a healthcare claim transaction may be received from a claims processor computer. Based at least in part on the reply, a determination may be made that the healthcare claim transaction has been rejected for an eligibility reason. An available payer for a patient associated with the received reply may be identified subsequent to the determination. Information associated with the identified available payer may be communicated to a healthcare provider associated with the healthcare claim transaction.

Claims

1. A method, comprising:

receiving, by a service provider system comprising one or more computers, a reply to a healthcare claim transaction from a claims processor computer;

determining, by the service provider system based at least in part on an evaluation of the reply, that the healthcare claim transaction has been rejected for an eligibility reason indicating either that a patient associated with the healthcare claim transaction is not covered for benefits or that incorrect coverage information was included in the healthcare claim transaction;

generating an eligibility request for the patient;

communicating the eligibility request to an eligibility system;

identifying, by the service provider system based at least in part on the determination that the healthcare claim transaction was rejected for an eligibility reason and a response to the eligibility request, an available payer for the patient; and

communicating, by the service provider system, information associated with the identified available payer to a healthcare provider associated with the healthcare claim transaction.

2. The method of claim 1, wherein communicating information associated with the identified payer comprises:

appending the information to the reply; and

communicating the reply to a healthcare provider computer associated with the healthcare provider.

3. The method of claim 1, wherein determining that the healthcare claim transaction has been rejected for an eligibility reason comprises:

identifying a reject code included in the received reply;

comparing the identified reject code to one or more stored reject codes associated with eligibility rejections; and

determining, based upon the comparison, that the healthcare claim transaction has been rejected for an eligibility reason.

4. The method of claim 3, wherein comparing the identified reject code to one or more stored reject codes comprises comparing the identified reject code to at least one of (i) a reject code for a missing or incomplete Banking Identification Number (BIN), (ii) a reject code for a missing or incomplete group number, (iii) a reject code for a missing or incomplete cardholder identifier, (iv) a reject code indicating that the healthcare claim transaction should be submitted to another processor, (v) a reject code for an unmatched group number, (vi) a reject code for an unmatched cardholder identifier, (vii) a reject code indicating that the patient is not covered, or (viii) a reject code indicating that the patient'"'"'s coverage has expired.

5. The method of claim 1, wherein the healthcare claim transaction comprises a first healthcare claim transaction, and further comprising:

generating, by the service provider system a second healthcare claim transaction on behalf of the patient; and

communicating, by the service provider system, the second healthcare claim transaction to a claims processing system associated with the identified available payer.

6. The method of claim 5, wherein the claims processor computer comprises a first claims processor computer associated with a first payer, and wherein communicating the second healthcare claim transaction to a claims processing system associated with the identified available payer comprises communicating the second healthcare claim transaction to one of (i) the first claims processor computer or (ii) a second claims processor computer associated with a second payer.

7. The method of claim 5, wherein the reply comprises a first reply, and further comprising:

receiving, by the service provider system from the claims processing system in response to the second healthcare claim transaction, a second reply; and

communicating, by the service provider system, the received second reply to a healthcare provider computer associated with the healthcare provider.

8. The method of claim 5, further comprising:

communicating, by the service provider system, a message to the healthcare provider indicating that the first healthcare claim transaction is being resubmitted.

9. 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 reply to a healthcare claim transaction from a claims processor computer;

determine, based at least in part on an evaluation of the reply, that the healthcare claim transaction has been rejected for an eligibility reason indicating either that a patient associated with the healthcare claim transaction is not covered for benefits or that incorrect coverage information was included in the healthcare claim transaction;

generate an eligibility request for the patient;

direct the communication of the eligibility request to an eligibility system;

identify, based at least in part on the determination that the healthcare claim transaction was rejected for an eligibility reason and a response to the eligibility request, an available payer for the patient; and

direct the communication of information associated with the identified available payer to a healthcare provider associated with the healthcare claim transaction.

10. The system of claim 9, wherein the at least one processor is configured to direct the communication of information associated with the identified available payer by executing the computer-executable instructions to:

append the information to the reply; and

direct the communication of the reply to a healthcare provider computer associated with the healthcare provider.

11. The system of claim 9, wherein the at least one processor is configured to determine that the healthcare claim transaction has been rejected for an eligibility reason by executing the computer-executable instructions to:

identify a reject code included in the received reply;

compare the identified reject code to one or more stored reject codes associated with eligibility rejections; and

determine, based upon the comparison, that the healthcare claim transaction has been rejected for an eligibility reason.

12. The system of claim 11, wherein the one or more stored reject codes comprise at least one of (i) a reject code for a missing or incomplete Banking Identification Number (BIN), (ii) a reject code for a missing or incomplete group number, (iii) a reject code for a missing or incomplete cardholder identifier, (iv) a reject code indicating that the healthcare claim transaction should be submitted to another processor, (v) a reject code for an unmatched group number, (vi) a reject code for an unmatched cardholder identifier, (vii) a reject code indicating that the patient is not covered, or (viii) a reject code indicating that the patient'"'"'s coverage has expired.

13. The system of claim 9, wherein the healthcare claim transaction comprises a first healthcare claim transaction, and wherein the at least one processor is further configured to execute the computer-executable instructions to:

generate a second healthcare claim transaction on behalf of the patient; and

direct communication of the second healthcare claim transaction to a claims processing system associated with the identified available payer.

14. The system of claim 13, wherein the claims processor computer comprises a first claims processor computer associated with a first payer, and wherein the claims processing system associated with the identified available payer comprises one of (i) the first claims processor computer or (ii) a second claims processor computer associated with a second payer.

15. The system of claim 13, wherein the reply comprises a first reply, and wherein the at least one processor is further configured to execute the computer-executable instructions to:

receive, from the claims processing system in response to the second healthcare claim transaction, a second reply; and

direct the communication of the received second reply to a healthcare provider computer associated with the healthcare provider.

16. The system of claim 13, wherein the at least one processor is further configured to execute the computer-executable instructions to:

direct the communication of a message to the healthcare provider indicating that the first healthcare claim transaction is being resubmitted.

17. A method, comprising:

receiving, by a service provider system comprising one or more computers, a reply to a healthcare claim transaction from a claims processor computer;

generating, by the service provider system based at least in part upon a determination that the healthcare claim transaction has been rejected for an eligibility reason, an eligibility request for a patient associated with the healthcare claim transaction;

communicating, by the service provider system, the eligibility request to an eligibility system;

identifying, by the service provider system based at least in part upon a response to the eligibility request received from the eligibility system, an available payer for the patient; and

communicating, by the service provider system, information associated with the identified available payer to a healthcare provider associated with the healthcare claim transaction.

18. The method of claim 17, wherein generating an eligibility request based upon a determination that the healthcare claim transaction has been rejected comprises:

identifying a reject code included in the received reply;

comparing the identified reject code to one or more stored reject codes associated with eligibility rejections;

determining, based upon the comparison, that the healthcare claim transaction has been rejected for an eligibility reason; and

generating the eligibility request based upon the determination that the healthcare claim transaction has been rejected for an eligibility reason.