System and method for submitting medication claims by point-of-care physicians

• US 8,370,172 B2
• Filed: 05/17/2007
• Issued: 02/05/2013
• Est. Priority Date: 05/17/2007
• Status: Expired due to Fees

• Current Assignee: Targeted Medical Pharma, Inc.
• Original Assignee: Targeted Medical Pharma, Inc.
• Inventors: Shell, William E., Charuvastra, Elizabeth
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): Holcomb, Mark
• Application Number:
  US11/804,085
• Publication Number:
  US 20080288281A1
• Time in Patent Office: 2,091 Days
• Field of Search: 705 2- 4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 20/13 delivered from dispensers

Abstract

A system for submitting a claim for a dispensed medication to a patient by a point-of-care physician including means acquiring at least one of the group consisting of a national practitioner number and a non pharmacy dispensing number for the point-of-care physician; means for displaying to a user a selection of data fields relating to the claim; means for inputting into the data fields data relating to the claim including the at least one of the group consisting of the national practitioner identifier number and the non pharmacy dispensing number; means for transmitting to a logic switch the claim containing the at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number identifying the point-of-care physician for determining the processor for the claim; means for determining the pathway for the claim based on a type of payor associated with the patient; means for processing the claim containing the at least one of the group consisting of a national practitioner identifier number and a non pharmacy dispensing number to identify the point-of-care physician; and responsive to the means for processing, means for transmitting to the point-of-care physician an adjudication regarding the claim.

Claims

1. A computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician comprising:

one or more non-transitory computer-readable media having tangibly embodied thereon one or more computer-executable instructions that are structure such that, when executed by one or more processors of said computer system, the computer system is configured to perform the following;

an act of acquiring at least one of the group consisting of a national provider identifier number and a non-pharmacy dispensing site number for said point-of-care physician;

an act of displaying to a user a selection of data fields relating to said claim;

an act of inputting into said data fields data relating to said claim including a payor, said dispensed medication, and said at least one of the group consisting of said national provider identifier number, said non-pharmacy dispensing site number;

responsive to said inputted payor, an act of producing an electronic form of one of a 1500 form and a universal drug form based on said payor, said producing said electronic form comprising inputting said at least one of said national provider identifier number and said non-pharmacy dispensing site number in a predetermined field in said produced electronic form of one of said 1500 form and said universal drug form;

an act of transmitting to a logic switch said produced electronic form containing said claim containing said payor, said dispensed medication, and said at least one of the group consisting of said national provider identifier number, said non-pharmacy dispensing site number identifying said point-of-care physician for determining the processor for said claim;

an act of determining the pathway for said claim, said act of determining comprising;

responsive to said payor being Medicare Part D, processing said national provider identifier number and said non-pharmacy dispensing site number;

responsive to said payor being Medicare Part B, processing said national provider identifier number;

responsive to said payor being private insurance, processing said national provider identifier number and said non-pharmacy dispensing number;

responsive to said payor being worker'"'"'s compensation, processing said national provider identifier number;

an act of processing by said payor said claim containing said at least one of the group consisting of a national provider identifier number and a non-pharmacy dispensing site number to identify said point-of-care physician; and

responsive to said act of processing, an act of transmitting to said point-of-care physician an adjudication regarding said claim.

2. The computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said act of transmitting further comprises

transmitting to said payor with a computerized NCPDP 5.1 link.

3. The computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said payor is selected from the group consisting of PPO private insurance, HMO private insurance, Champus, and Medicaid.

4. The computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said data fields are selected from the group consisting of transaction format for prescription, BIN, version number, transaction code, processor code, pharmacy number, group number, cardholder identification number, date of fill, prescription number, response format, response status, response data, claim reversal format, date of fill, prescription number, worker'"'"'s compensation claim format, Medicare claim format, claim payable response format, and claim captured response format.

5. The computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 further comprising:

an act of reimbursing said point-of-care physician for said submitted pharmaceutical or Medical Food claim.

6. The computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 further comprising:

an act of verifying the existence of a contract between said point-of-care physician and said payor.

7. The computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 further comprising:

an act of obtaining a contract between said point-of-care physician and said payor.

8. The computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 1 wherein said adjudication comprises a message containing information related to said processed claim selected from the group consisting of status of receipt by said one or more processors, status of review by said processor, and status of disposition.

9. An electronic computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician comprising:

an electronic input device for producing input signals;

a display;

an electronic memory storing at least one of the group consisting of national provider identifier number, non-pharmacy dispensing site number, transaction format for prescription, BIN, version number, transaction code, processor code, pharmacy number, group number, cardholder identification number, date of fill, prescription number, response format, response status, response data, claim reversal format, date of fill, prescription number, worker'"'"'s compensation claim format, Medicare claim format, claim payable response format, and claim captured response format; and

an electronic processor communicating with said memory and said display and responsive to the input signals to;

direct said display to display a data field relating to said at least one of said group consisting of national provider identifier number, non-pharmacy dispensing site number, transaction format for prescription, BIN, version number, transaction code, processor code, pharmacy number, group number, cardholder identification number, date of fill, prescription number, response format, response status, response data, claim reversal format, date of fill, prescription number, worker'"'"'s compensation claim format, Medicare claim format, claim payable response format, and claim captured response format;

receive input into said data field relating to said claim including a payor, said dispensed medication, and said at least one of the group consisting of said national provider identifier number, said non-pharmacy dispensing site number;

responsive to said inputted payor, produce an electronic form of one of a 1500 form and a universal drug form based said payor, said producing said electronic form comprising inputting said at least one of said national provider identifier number and said non-pharmacy dispensing site number in a predetermined field in said produced electronic form of one of said 1500 form and said universal drug form;

transmit to a logic switch said produced electronic form containing said claim containing said at least one of the group consisting of a national provider identifier number, a non-pharmacy dispensing site number identifying said point-of-care physician for determining the processor for said claim;

determine the pathway for said claim, said determine comprising;

responsive to said payor being Medicare Part D, process said national provider identifier number and said non-pharmacy dispensing site number;

responsive to said payor being Medicare Part B, process said national provider identifier number;

responsive to said payor being private insurance, process said national provider identifier number and said non-pharmacy dispensing number;

responsive to said payor being worker'"'"'s compensation, process said national provider identifier number;

process by said payor said claim containing said at least one of the group consisting of a national provider identifier number and a non-pharmacy dispensing site number to identify said point-of-care physician; and

responsive to said processing, transmit to said point-of-care physician an adjudication regarding said claim.

10. The electronic computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 9 wherein

said transmit further comprises a computerized NCPDP 5.1 link.

11. The electronic computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 9 wherein said payor is selected from the group consisting of PPO private insurance, HMO private insurance, Champus, and Medicaid.

12. The electronic computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 9 wherein the electronic processor is further responsive to input signals to:

verify the existence of a contract between said point-of-care physician and said payor.

13. The electronic computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 9 wherein the electronic processor is further responsive to input signals to:

obtain a contract between said point-of-care physician and said payor.

14. The electronic computer system for submitting a claim for a dispensed medication to a patient by a point-of-care physician of claim 9 wherein said adjudication comprises a message containing information related to said processed claim selected from the group consisting of status of receipt by said processor, status of review by said processor, and status of disposition.