Systems and methods for real-time monitoring and analysis of prescription claim rejections

• US 8,626,525 B2
• Filed: 06/23/2008
• Issued: 01/07/2014
• Est. Priority Date: 06/23/2008
• Status: Active Grant

• Current Assignee: McKesson Corp.
• Original Assignee: Mckesson Financial Holdings Limited (McKesson Corp.)
• Inventors: Mi, Zhe Cheng, Russell, Rita Sue
• Primary Examiner(s): NGUYEN, HIEP VAN
• Application Number:
  US12/144,293
• Publication Number:
  US 20090319311A1
• Time in Patent Office: 2,024 Days
• Field of Search: 705/2
• 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

Embodiments of the invention can provide systems and methods for real-time monitoring and analysis of prescription claim rejections. In one embodiment, a transaction performance monitoring system for facilitating real-time monitoring of the rejection of claims can be provided. The transaction performance monitoring system can include a transaction performance monitoring application operable to receive a plurality of claims associated with at least one dispenser, wherein each of the claims relates to at least one prescription and at least one payor. In addition, a transaction performance monitoring application operable to, in real-time, identify rejected claims and associated causes of the rejected claims. Furthermore, a transaction performance monitoring system can include a network operable to communicate the plurality of claims between the at least one dispenser and the at least one payor.

Claims

1. A transaction performance monitoring system for facilitating real-time monitoring of the rejection of claims, the transaction performance monitoring system comprising:

a transaction performance monitoring application operable to;

receive a plurality of claims associated with at least one dispenser, wherein each of the claims relates to at least one prescription and at least one payor;

in real-time, identify rejected claims and associated causes of the rejected claims, wherein the rejected claims and associated causes are aggregated to define a total number of rejected claims and a total number for each associated cause; and

provide a user interface for the at least one payor to monitor inbound and outbound claim traffic in real-time, and to view the total number of rejected claims and total number for each associated cause at an interface level, BIN level, reject code level, reject code level within an interface, or a reject code level within a BIN;

provide a user interface for setting at least one alert triggered by a predefined percentage of rejected claims or by a predefined number of rejected claims, wherein the rejected claims are at a predefined level comprising at least one of an interface level, BIN level, reject code level within an interface, or reject code within a BIN; and

a network operable to;

communicate the plurality of claims between the at least one dispenser and the at least one payor.

2. The system of claim 1, wherein the performance monitoring application is further operable to:

provide a user interface for monitoring rejected claims and the associated causes of the rejected claims.

3. The system of claim 2, wherein the user interface is operable to provide at least one of the following:

summary information associated with a specific interface, one or more user specified parameters, a rejected claim total for a defined time period, or a status history associated with aggregated rejected claims.

4. The system of claim 1, wherein the performance monitoring application is further operable to:

provide a real-time status of aggregated rejected claims and the associated causes of the rejected claims.

5. The system of claim 1, wherein the performance monitoring application is further operable to:

in real-time, identify rejected claims and associated causes of the rejected claims based at least in part on determining at least one respective rejection code associated with each of the rejected claims.

6. The system of claim 1, wherein the performance monitoring application is further operable to:

provide a user interface for setting at least one alert triggered by a predefined percentage or number of rejected claims at a predefined level.

7. The system of claim 6, wherein the predefined level comprises at least one of the following:

interface level, BIN level, reject code level, reject code level within an interface, or reject code level within a BIN.

8. The system of claim 1, wherein the performance monitoring application is further operable to:

output at least one report comprising real-time data associated with rejected claims and associated causes of the rejected claims.

9. A method for facilitating real-time monitoring of the rejection of claims communicated between at least one dispenser and at least one payor, the method comprising:

receiving, by at least one processor, a plurality of claims associated with at least one dispenser, wherein each of the claims relates to at least one prescription and at least one payor;

in real-time, identifying, by the at least one processor, rejected claims and associated causes of the rejected claims, wherein the rejected claims and associated causes are aggregated to define a total number of rejected claims and a total number for each associated cause;

setting at least one alert triggered by a predefined percentage of rejected claims or by a predefined number of rejected claims, wherein the rejected claims are at a predefined level comprising at least one of an interface level, BIN level, reject code level within an interface, or reject code within a BIN; and

outputting, by the at least one processor, a real-time display of aggregated rejected claims and associated causes of the rejected claims, wherein the at least one payor can monitor inbound and outbound claim traffic in real-time, and view the total number of rejected claims and total number for each associated cause at an interface level, BIN level, reject code level, reject code level within an interface, or a reject code level within a BIN.

10. The method of claim 9, wherein identifying rejected claims and associated causes of the rejected claims comprises determining at least one respective rejection code associated with each of the rejected claims.

11. The method of claim 9, wherein identifying rejected claims and associated causes of the rejected claims comprises determining at least one NCPDP (National Council for Prescription Drug Programs) reject code associated with each rejected claim.

12. The method of claim 9, further comprising:

setting at least one alert triggered by a predefined percentage or number of rejected claims at a predefined level.

13. The method of claim 12, wherein the predefined level comprises at least one of the following:

interface level, BIN level, reject code level, reject code level within an interface, or reject code level within a BIN.

14. The method of claim 9, wherein the display further comprises at least one of the following:

summary information associated with a specific interface, one or more user specified parameters, a rejected claim total for a defined time period, or a status history associated with aggregated rejected claims.

15. A transaction performance monitoring application for facilitating real-time monitoring of the rejections of claims communicated between at least one dispenser and at least one payor via a network, the transaction performance monitoring application comprising computer-readable instructions operable to:

receive a plurality of claims associated with at least one dispenser, wherein each of the plurality of claims relates to at least one prescription and at least one payor;

in real-time, identify rejected claims and associated causes of the rejected claims, wherein the rejected claims and associated causes are aggregated to define a total number of rejected claims and a total number for each associated cause;

determining at least one NCPDP (National Council for Prescription Drug Programs) reject code associated with each rejected claim;

provide a user interface for monitoring, in real-time, rejected claims and the associated causes of the rejected claims, wherein the at least one payor can monitor inbound and outbound claim traffic in real-time, and view the total number of rejected claims and total number for each associated cause at an interface level, BIN level, reject code level, reject code level within an interface, or a reject code level within a BIN;

provide a user interface for setting at least one alert triggered by a predefined percentage of rejected claims or by a predefined number of rejected claims, wherein the rejected claims are at a predefined level comprising at least one of an interface level, BIN level, reject code level within an interface, or reject code within a BIN; and

communicate at least a portion of the plurality of claims between the at least one dispenser and the at least one payor.

16. The transaction performance monitoring application of claim 15, wherein the computer-readable instructions are further operable to:

provide a real-time status of aggregated rejected claims and the associated causes of the rejected claims.

17. The transaction performance monitoring application of claim 15, wherein the computer-readable instructions are further operable to:

in-real-time, identify rejected claims and associated causes of the rejected claims based at least in part on determining at least one respective rejection code associated with each of the rejected claims.

18. The transaction performance monitoring application of claim 15, wherein the computer-readable instructions are further operable to:

provide a user interface for setting at least one alert triggered by a predefined percentage or number of rejected claims at a predefined level.

19. The transaction performance monitoring application of claim 18, wherein the predefined level comprises at least one of the following:

interface level, BIN level, reject code level, reject code level within an interface, or reject code level within a BIN.

20. The transaction performance monitoring application of claim 15, wherein the computer-readable instructions are further operable to:

output at least one report comprising real-time data associated with rejected claims and associated causes of the rejected claims.