Systems and methods for determining product pricing for products in a healthcare transaction
Inventors
Harris, Patrick • Turner, William
Assignees
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Publication Number
US-10713694-B1
Publication Date
2020-07-14
Expiration Date
Abstract
Systems and methods are provided for determining and communicating proper pricing information and other pre- and post-adjudication information, such as an availability of a lower price for a prescription, as part of the processing of a healthcare transaction. A healthcare transaction, such as a healthcare claim transaction, may be received by the service provider computer from a pharmacy computer. The service provider computer may determine if an adjudication platform is available for the prescribed product. The service provider computer may generate a modified healthcare claim transaction and transmit the modified healthcare claim transaction to a claims processor computer for adjudication. The service provider computer may receive an approved adjudicated claim transaction response and perform any post-adjudication on the response. The approved adjudicated claim transaction response may be transmitted to the pharmacy.
Core Innovation
A computer-implemented method operated by one or more computers as a service provider in a network receives, from a pharmacy computer associated with a pharmacy, a prescription claim request communicated via network interfaces. The prescription claim request identifies at least a product identifier for a prescribed product, a pharmacy identifier for the pharmacy, a claims processor identifier identifying a claims processor computer operative in the network and remote from the pharmacy computer and service provider, and a usual and customary cost corresponding to the prescribed product established by the pharmacy.
The method determines that at least one pre-adjudication service associated with the service provider is available for the prescribed product, and accesses, on a database, one or more data files comprising at least a pricing schema file for the identified pharmacy. The pricing schema file comprises a cost to the identified pharmacy to acquire the prescribed product, and includes pharmacy level discount information including at least one of a pharmacy loyalty program or a pharmacy reward program established by the pricing schema for the identified pharmacy.
The method determines, by processing the pricing schema file, that a price lower than the usual and customary cost is available for the prescribed product, where the lower price is available due to at least the pharmacy loyalty program or the pharmacy reward program. It generates a modified prescription claim request by replacing the cost of the prescribed product in the prescription claim request with the lower price, transmits the modified prescription claim request to the claims processor computer for benefits adjudication, receives an approved adjudicated response, and transmits the approved adjudicated response to the pharmacy computer.
The method causes the pricing schema file to be updated on the database via a network interface of the pharmacy computer as new pricing data becomes available, wherein the one or more computers operating as the service provider retrieves real-time or near real-time pricing data maintained by the pharmacy computer. The described workflow can further include additional pre-adjudication services and post-adjudication services, along with post-processing such as producing a modification report describing modifications to a prescription claim request or an approved adjudicated response.
Claims Coverage
The document contains two independent claims: a computer-implemented method and a system. Across these independent claims, there are five main inventive features.
Receiving a prescription claim request with identifiers and usual and customary cost
Receiving, by one or more computers operating as a service provider in a network, and from a pharmacy computer associated with a pharmacy and operative in the network, a prescription claim request identifying at least a product identifier for a prescribed product, a pharmacy identifier for the pharmacy, a claims processor identifier identifying a claims processor computer operative in the network and remote from the pharmacy computer and service provider, and a usual and customary cost corresponding to the prescribed product established by the pharmacy.
Determining availability of pre-adjudication service or adjudication platform
Determining, by the at least one processor of the one or more computers, that at least one pre-adjudication service associated with the one or more computers is available for the prescribed product; wherein the one or more computers operating as the service provider determine that an adjudication platform associated with the at least one processor is available for the prescribed product.
Accessing pricing schema file and identifying lower price from loyalty/reward discount information
Accessing, on a database, one or more data files comprising at least a pricing schema file for the identified pharmacy, wherein the pricing schema file comprises a cost to the identified pharmacy to acquire the prescribed product, and determining by processing the pricing schema file that a price, lower than the usual and customary cost, is available at the pharmacy for the prescribed product, wherein the lower price is available due to at least a pharmacy loyalty program or a pharmacy reward program established by the pricing schema for the identified pharmacy, and wherein the pricing schema includes a cost to the pharmacy to acquire the prescribed product and pharmacy level discount information including at least one of the pharmacy loyalty program or the pharmacy reward program.
Generating a modified prescription claim request with the lower price and transmitting for benefits adjudication
Generating a modified prescription claim request by replacing the cost of the prescribed product in the prescription claim request with the lower price for the prescribed product, and transmitting, via the network interface, the modified prescription claim request to the claims processor computer for a benefits adjudication.
Returning an approved adjudicated response and updating pricing schema with real-time or near real-time data
Receiving an approved adjudicated response to the modified prescription claim request and transmitting the approved adjudicated response to the pharmacy computer, and causing the pricing schema file to be updated on the database via the network interface of the pharmacy computer as new pricing data becomes available, wherein the one or more computers operating as the service provider retrieves real-time or near real-time pricing data maintained by the pharmacy computer.
The independent claims cover a service-provider network workflow that uses pharmacy-specific pricing schema file data, including pharmacy loyalty or reward program discount information, to replace a prescription claim request’s usual and customary cost with a lower available price, transmit the modified request for benefits adjudication, and return an approved adjudicated response to the pharmacy, while updating pricing schema data with real-time or near real-time pricing.
Stated Advantages
Enables benefits adjudication using a modified prescription claim request in which the cost is replaced with a lower price available at the pharmacy based on pharmacy loyalty program or pharmacy reward program discount information.
Documented Applications
A networked healthcare transaction system in which a service provider receives a pharmacy-submitted prescription claim request, uses pricing schema data to find and apply a lower price, transmits the modified request for benefits adjudication, and returns an approved adjudicated response to the pharmacy, with pricing schema updates using real-time or near real-time pharmacy pricing data.
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