Systems and methods for a prescription safety network utilizing eligibility verification transactions

• US 8,386,274 B1
• Filed: 09/17/2008
• Issued: 02/26/2013
• Est. Priority Date: 09/17/2008
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: Mckesson Financial Holdings Limited (McKesson Corp.)
• Inventors: Pinsonneault, Roger
• Primary Examiner(s): Pauls, John
• Application Number:
  US12/212,129
• Time in Patent Office: 1,623 Days
• Field of Search: 705 2- 4, 600300-301
• US Class Current: 705/2
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

Systems and methods may be provided for a prescription safety network program. The systems and methods may include receiving an eligibility verification request for a prescribed drug or product, where the eligibility verification request may include a pharmacy identifier, a patient identifier, and physician identifier; determining, based upon the received pharmacy identifier, that a pharmacy associated with the pharmacy identifier has enrolled in the prescription safety network program for filling the prescribed drug or product; determining, based upon the received patient identifier, that a patient associated with the patient identifier has enrolled in the prescription safety network program for utilizing the prescribed drug or product; and determining, based upon the received physician identifier, that a physician associated with the physician identifier has enrolled in the prescription safety network program for prescribing the prescribed drug or product; and generating an approval authorization by the validation engine in response to the eligibility verification request.

Claims

1. A method for a prescription safety network program, comprising:

receiving, by at least one provider computer from a pharmacy computer, an eligibility verification request for a prescribed drug, wherein the eligibility verification request includes a pharmacy identifier, a patient identifier, and a physician identifier;

determining, by the at least one provider computer based upon comparing the received pharmacy identifier to stored information associated with pharmacies having one of (i) a Drug Enforcement Agency (DEA) number, (ii) a National Provider Identifier (NPI), or (iii) a state license that permits dispensing the prescribed drug, that a requesting pharmacy associated with the pharmacy identifier is authorized for filling the prescribed drug;

determining, by the at least one provider computer based upon the received patient identifier, that a patient associated with the patient identifier is authorized for utilizing the prescribed drug;

determining, by the at least one provider computer based upon the received physician identifier, that a physician associated with the physician identifier is authorized for prescribing the prescribed drug;

generating based on a positive determination that the requesting pharmacy is authorized to fill the prescribed drug, the patient is authorized to utilize the prescribed drug, and the physician is authorized to prescribe the prescribed drug, an approval authorization by the at least one provider computer, the approval authorization comprising an authorization ID;

delivering, by the at least one provider computer, the generated approval authorization to the pharmacy computer in response to the eligibility verification request, wherein the approval authorization permits the pharmacy to submit a prescription claim request requesting payment for the prescribed drug;

subsequent to delivering the approval authorization, receiving, by the at least one provider computer from the pharmacy computer, the prescription claim request for the prescribed drug, the prescription claim request comprising a received authorization ID;

evaluating the received authorization ID to determine if the received authorization ID matches the authorization ID delivered with the approval authorization;

delivering the prescription claim request from the at least one provider computer to a third-party processing system for payment adjudication based on positive determination that the received authorization ID matches the authorization ID delivered with the approval authorization

receiving an adjudicated claim response at the at least one provider computer from the third-party processing system; and

delivering, by the at least one provider computer, the adjudicated claim response to the pharmacy computer in response to the prescription claim request, wherein the delivery of the approval authorization and the adjudicated claim response permits the pharmacy to dispense the prescribed drug to the patient.

2. The method of claim 1, wherein one or more of the pharmacy, patient, and physician enrolls with the prescription safety network program via a call center, interactive voice response system, or Internet website/portal prior to being authorized for filling, utilizing, or prescribing the prescribed drug.

3. The method of claim 2, wherein in association with enrollment with the prescription safety network program, one or more of the pharmacy, patient, and physician receive educational information relating to the prescribed drug.

4. The method of claim 3, wherein the educational information includes medication guides or safety guides for the prescribed drug.

5. The method of claim 1, wherein prior to delivering the approval authorization, the method further includes determining, by the at least one provider computer, that information of the patient is compliant with manufacturer or safety specifications for the prescribed drug.

6. The method of claim 1, wherein the eligibility verification request is associated with a standard National Council for Prescription Drug Programs (NCPDP) eligibility verification transaction, and further comprising:

identifying, by the at least one provider computer based upon a Banking Identification Number (BIN)/Processor Control Number (PCN) included in the eligibility verification request, the prescribed drug.

7. The method of claim 1, wherein if the received authorization ID does not match the authorization ID delivered with the approval authorization, then the prescription claim request is processed by delivering a message from the at least one provider computer to the pharmacy computer, the message comprising an indication that the received authorization ID is invalid.

8. The method of claim 7, wherein the adjudication by the third-party processing system results in a determination of a patient-responsible amount payable by the patient when the pharmacy dispenses the prescribed drug to the patient.

9. The method of claim 1, further comprising the step of:

based on a determination that at least one of the requesting pharmacy, the patient, and the physician are not enrolled with the prescription safety network program, generating and transmitting a denial of authorization from the provider computer to the pharmacy computer.

10. The method of claim 9, wherein the denial of authorization prevents the pharmacy from providing the prescribed drug to the patient by disallowing a request for payment by the pharmacy for the prescribed drug.

11. A system for a prescription safety network program, comprising:

a memory for storing computer-executable instructions;

a processor in communication with the memory, wherein the processor is configured to execute the computer-executable instructions to;

receive, from a pharmacy computer, an eligibility verification request for a prescribed drug, wherein the eligibility verification request includes a pharmacy identifier, a patient identifier, and a physician identifier;

determine, based upon comparing the received pharmacy identifier to stored information associated with pharmacies having one of (i) a Drug Enforcement Agency (DEA) number, (ii) a National Provider Identifier (NPI), or (iii) a state license that permits dispensing the prescribed drug, that a requesting pharmacy associated with the pharmacy identifier is authorized for filling the prescribed drug;

determine, based upon the received patient identifier, that a patient associated with the patient identifier is authorized for utilizing the prescribed drug;

determine, based upon the received physician identifier, that a physician associated with the physician identifier is authorized for prescribing the prescribed drug;

generate, based upon a positive determination that the requesting pharmacy is authorized to fill the prescribed drug, the patient is authorized to utilize the prescribed drug, and the physician is authorized to prescribe the prescribed drug, an approval authorization comprising an authorization ID;

direct communication of the generated approval authorization to the pharmacy computer in response to the eligibility verification request, wherein the approval authorization permits the pharmacy to submit a prescription claim request requesting payment for the prescribed drug;

subsequent to directing communication of the generated approval authorization, receive, from the pharmacy computer, the prescription claim request for the prescribed drug, the prescription claim request comprising a received authorization ID;

evaluate the received authorization ID to determine if the received authorization ID matches the authorization ID of the approval authorization;

direct communication of the prescription claim request to a third-party processing system for payment adjudication based on a positive determination that the received authorization ID matches the authorization ID of the approval authorization;

receive an adjudicated claim response from the third-party processing system; and

direct communication of the adjudicated claim response to the pharmacy computer in response to the prescription claim request, wherein the delivery of the approval authorization and the adjudicated claim response permits the pharmacy to dispense the prescribed drug to the patient.

12. The system of claim 11, wherein one or more of the pharmacy, patient, and physician enrolls with the prescription safety network program via a call center, interactive voice response system, or Internet website/portal prior to being authorized for filling, utilizing, or prescribing the prescribed drug.

13. The system of claim 12, wherein in association with enrollment with the prescription safety network program, one or more of the pharmacy, patient, and physician receive educational information relating to the prescribed drug.

14. The system of claim 13, wherein the educational information includes medication guides or safety guides for the prescribed drug.

15. The system of claim 11, wherein prior to delivering the approval authorization, the processor is further configured to execute the computer-executable instructions to determine that information of the patient is compliant with manufacturer or safety specifications for the prescribed drug.

16. The system of claim 11, wherein the eligibility verification request is associated with a standard National Council for Prescription Drug Programs (NCPDP) eligibility verification transaction, and wherein the processor is further configured to evaluate a Banking Identification Number (BIN)/Processor Control Number (PCN) included in the eligibility verification request to determine the prescribed drug.

17. The system of claim 11, wherein if the received authorization ID-does not match the authorization ID delivered with the approval authorization, then the prescription claim request is processed by delivering a message from the at least one provider computer to the pharmacy computer, the message comprising an indication that the received authorization ID is invalid.

18. The system of claim 17, wherein the adjudication by the third-party processing system results in a determination of a patient-responsible amount payable by the patient when the pharmacy dispenses the prescribed drug to the patient.

19. The system of claim 11, wherein the processor is further configured to execute the computer-executable instructions to:

based on a determination that at least one of the requesting pharmacy, the patient, and the physician are not enrolled with the prescription safety network program, generate a denial of authorization and direct communication of the denial of authorization to the pharmacy computer.

20. The system of claim 19, wherein the denial of authorization prevents the pharmacy from providing the prescribed drug to the patient by disallowing a request for payment by the pharmacy for the prescribed drug.