Systems and methods for facilitating claim rejection resolution by providing prior authorization assistance

• US 8,392,214 B1
• Filed: 11/30/2010
• Issued: 03/05/2013
• Est. Priority Date: 11/30/2010
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: Mckesson Financial Holdings Limited (McKesson Corp.)
• Inventors: Pinsonneault, Roger
• Primary Examiner(s): Cobanoglu, Dilek B
• Application Number:
  US12/957,106
• Time in Patent Office: 826 Days
• Field of Search: 705/2, 705/3, 705/4, 705/32, 705/50, 235/378
• US Class Current: 705/2
• 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 providing prior authorization support. The systems and methods may include receiving a first request for prior authorization assistance from a pharmacy computer, wherein the request for assistance includes claim identification information for a prior healthcare claim transaction; identifying a stored transaction history record for the prior healthcare claim transaction, where the stored transaction record is identified based at least in part on the claim identification information, where the stored transaction history record indicates a denial of coverage by a payor of a drug or product for a patient; delivering, to a prior authorization assistance computer, a second request for prior authorization assistance, where the information included in the second request enables the prior authorization assistance computer to initiate a process for completing a prior authorization form and for delivering the completed form to the payor; and delivering, to the pharmacy computer, a response indicating acceptance of the first request for assistance.

Claims

1. A method, comprising:

receiving a first request for prior authorization assistance from a pharmacy computer associated with a pharmacy, wherein the request for prior authorization assistance includes claim identification information for a prior healthcare claim transaction;

identifying a stored transaction history record for the prior healthcare claim transaction, wherein the stored transaction record is identified based at least in part on the claim identification information from the request for prior authorization assistance, wherein the stored transaction history record indicates a denial of coverage by a payor of a drug or product for a patient;

preparing a second request for prior authorization assistance, the second request based at least in part on information from the stored transaction history record, wherein the second request identifies at least patient information, identification of the drug or product for the patient, and identification of the payor;

delivering, to a prior authorization assistance computer, the second request for prior authorization assistance, wherein the information included in the second request enables the prior authorization assistance computer to initiate a process for completing a prior authorization form and for delivering the completed prior authorization form to the payor; and

delivering, to the pharmacy computer, a response indicating acceptance of the first request for prior authorization assistance, wherein the response is stylized as a paid response or a rejection response based upon preferences of the pharmacy;

wherein the prior steps are performed by one or more computers associated with a service provider.

2. The method of claim 1, wherein one or both of the first request for prior authorization assistance and the second request for prior authorization assistance is in a form of a billing claim request conventionally utilized for requesting financial reimbursement.

3. The method of claim 2, wherein one or both of the first request and the second request utilize a particular BIN Number or combination of the particular BIN Number and a Processor Control Number (PCN) to indicate a request for prior authorization assistance.

4. The method of claim 1, wherein prior to receiving the first request for prior authorization assistance, the method further includes:

receiving a healthcare claim request from the healthcare provider computer, wherein the healthcare transaction request identifies the drug or product for the patient;

delivering the healthcare claim request to a claims processor computer associated with the payor for processing or adjudication;

receiving a rejection response for the healthcare transaction request from the claims processor computer, wherein the healthcare transaction request and the rejection response are part of a healthcare transaction, wherein the rejection response includes a reject code that indicates the denial of coverage for the drug or product;

determining, based at least in part upon the reject code and the identified drug or product, that the healthcare transaction is qualified for prior authorization assistance; and

storing, based upon the determination, the transaction history record, wherein the transaction history record includes information from one or both of the healthcare claim request and the rejection response,

wherein the prior steps are performed by one or more computers associated with a service provider.

5. The method of claim 4, further comprising:

delivering a second response to the pharmacy computer, the second response indicating the denial of coverage for the drug or product and an availability of prior authorization assistance,

wherein the prior step is performed by one or more computers associated with a service provider.

6. The method of claim 4, wherein the prior authorization assistance computer is either (i) part of the one or more computers of the service provider, or (ii) another computer of the service provider.

7. The method of claim 4, wherein the prior authorization form is further completed using information from the identified stored transaction history record.

8. The method of claim 4, wherein both the claim identification information and the stored transaction history record includes at least (i) an identifier of the payor, (ii) an identifier of the drug or product, (iii) a date of service, (iv) a prescription/service reference number, and (v) an identifier of the pharmacy.

9. The method of claim 1, further comprising:

receiving a second response from the prior authorization computer, the second response indicating one of (i) receipt of the completed prior authorization form, (ii) delivery of the completed prior authorization form to the payor, or (iii) a result of the payor processing the completed prior authorization form; and

delivering information from the second response to the pharmacy computer,

wherein the prior steps are performed by one or more computers associated with a service provider.

10. The method of claim 1, wherein the response is stylized as the paid response, wherein the patient-responsible amount of the paid response is set to a full price of the drug or product.

11. A system, comprising:

at least one memory for storing computer-executable instructions;

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

receive a first request for prior authorization assistance from a pharmacy computer associated with a pharmacy, wherein the request for prior authorization assistance includes claim identification information for a prior healthcare claim transaction;

identify a stored transaction history record for the prior healthcare claim transaction, wherein the stored transaction record is identified based at least in part on the claim identification information from the request for prior authorization assistance, wherein the stored transaction history record indicates a denial of coverage by a payor of a drug or product for a patient;

prepare a second request for prior authorization assistance, the second request based at least in part on information from the stored transaction history record, wherein the second request identifies at least patient information, identification of the drug or product for the patient, and identification of the payor;

deliver, to a prior authorization assistance computer, the second request for prior authorization assistance, wherein the information included in the second request enables the prior authorization assistance computer to initiate a process for completing a prior authorization form and for delivering the completed prior authorization form to the payor; and

deliver, to the pharmacy computer, a response indicating acceptance of the first request for prior authorization assistance, wherein the response is stylized as a paid response or a rejection response based upon preferences of the pharmacy.

12. The system of claim 11, wherein one or both of the first request for prior authorization assistance and the second request for prior authorization assistance is in a form of a billing claim request conventionally utilized for requesting financial reimbursement.

13. The system of claim 12, wherein one or both of the first request and the second request utilize a particular BIN Number or combination of the particular BIN Number and a Processor Control Number (PCN) to indicate a request for prior authorization assistance.

14. The system of claim 11, wherein prior to receiving the first request for prior authorization assistance, the at least one processor is further configured to execute the computer-executable instructions to:

receive a healthcare claim request from the healthcare provider computer, wherein the healthcare transaction request identifies the drug or product for the patient;

deliver the healthcare claim request to a claims processor computer associated with the payor for processing or adjudication;

receive a rejection response for the healthcare transaction request from the claims processor computer, wherein the healthcare transaction request and the rejection response are part of a healthcare transaction, wherein the rejection response includes a reject code that indicates the denial of coverage for the drug or product;

determine, based at least in part upon the reject code and the identified drug or product, that the healthcare transaction is qualified for prior authorization assistance; and

store, based upon the determination, the transaction history record, wherein the transaction history record includes information from one or both of the healthcare claim request and the rejection response.

15. The system of claim 14, wherein the at least one processor is further configured to execute the computer-executable instructions to:

deliver a second response to the pharmacy computer, the second response indicating the denial of coverage for the drug or product and an availability of prior authorization assistance.

16. The system of claim 14, wherein the at least one processor is part of one or more computers of a service provider.

17. The system of claim 14, wherein the prior authorization form is further completed using information from the identified stored transaction history record.

18. The system of claim 14, wherein both the claim identification information and the stored transaction history record includes at least (i) an identifier of the payor, (ii) an identifier of the drug or product, (iii) a date of service, (iv) a prescription/service reference number, and (v) an identifier of the pharmacy.

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

receive a second response from the prior authorization computer, the second response indicating one of (i) receipt of the completed prior authorization form, (ii) delivery of the completed prior authorization form to the payor, or (iii) a result of the payor processing the completed prior authorization form; and

deliver information from the second response to the pharmacy computer.

20. The system of claim 11, wherein the response is stylized as the paid response, wherein the patient-responsible amount of the paid response is set to a full price of the drug or product.