Prescription prior authorization system
Inventors
Pinsonneault, Roger G. • Kaye, Elizabeth S.
Assignees
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Publication Number
US-10742654-B1
Publication Date
2020-08-11
Expiration Date
Abstract
An improved prescription prior authorization system is disclosed and described herein. The improved prescription prior authorization system provides an improved system and apparatus for prescription prescribers and other healthcare providers to satisfy prior authorization requirements as part of the prescription process. The improved prescription prior authorization system provides mechanisms to a prescriber of medication to more quickly and efficiently satisfy prior authorization requirements for a prescriber and to more quickly provide the prescription to the patient to improve the patient's overall health. The patient's overall health is improved because of the improved likelihood that the patient will receive the product that the prescriber wants to prescribe to the patient. The improved prescription prior authorization system also reduces prescription network traffic and improves the efficiency of the prescription network.
Core Innovation
The disclosed prescription prior authorization system facilitates interaction between a prescriber and a pharmacist by electronically receiving an electronic prior authorization request that includes a plurality of data fields comprising at least one patient identifier, a product identifier, a request type identifier, and a prescriber identifier. The system identifies the request type identifier, determines evaluation parameters for evaluating the electronic prior authorization request, determines required data fields, and evaluates each required data field to determine whether required data fields do not include data.
When at least one required data field is determined not to include data and an associated electronic healthcare record (EHR) field of the identified patient is populated, the system adds a data element to the determined required data fields from the associated EHR field and prompts a user of the prescription prior authorization system to review and accept the added data element. When an associated EHR field is not populated, the system prompts the user to review and manually add data to the required data fields.
The system also determines a format for the data in at least a portion of the plurality of data fields, compares the format of the data to a required format, and, when the format differs, modifies the format to match the required format and prompts the user to review and accept the modified format, where the format comprises at least one of a data character length or a data character type. The system directs communication of the electronic prior authorization request to a pharmacy claims processor computer for processing, receives an electronic prior authorization response, identifies a medication identifier in the response, determines a non-insurance based patient financial assistance opportunity that reduces or eliminates patient financial responsibility, retrieves a non-insurance based patient financial assistance opportunity message, inserts the message into the response, and electronically directs the response and message for receipt by the prescriber computer.
Claims Coverage
Independent claims include seven inventive features covering reception of an electronic prior authorization request, request-type-based determination of evaluation parameters and required data fields, conditional EHR-based data element addition or manual review, data format comparison with conditional modification, forwarding to a pharmacy claims processor, and response enhancement with a non-insurance based patient financial assistance opportunity message, for both a system and a computer-implemented method.
Receiving an electronic prior authorization request with identifiers and request type
electronically receive an electronic prior authorization request originating from a prescriber computer associated with a prescriber of a product to a patient, wherein the electronic prior authorization request comprises a plurality of data fields comprising at least one patient identifier, a product identifier, a request type identifier, and a prescriber identifier
Determining evaluation parameters and required data fields
identify the request type identifier in the electronic prior authorization request; determine, based at least on the request type identifier, at least one evaluation parameter for evaluating the electronic prior authorization request; determine, based at least on the at least one evaluation parameter, a plurality of required data fields in the electronic prior authorization request; evaluate each of the plurality of required data fields
EHR-based population of missing required data with user prompt
determine, based at least on the evaluation, if at least one of the required data fields in the electronic prior authorization request does not include data; in an instance in which at least one of the required data fields is determined to not include data based at least on the evaluation and an associated electronic healthcare record (EHR) field of the identified patient is populated: (a) add a data element to the determined at least one required data fields from the associated EHR field, and (b) prompt a user to review and accept the added data element
Manual review when associated EHR field is not populated
in an instance in which at least one of the required data fields is determined to not include data based at least on the evaluation and an associated electronic healthcare record (EHR) field of the identified patient is not populated, prompt the user to review and manually add data to the required data fields
Forwarding to pharmacy claims processor and receiving prior authorization response
electronically direct communication of the electronic prior authorization request to a pharmacy claims processor computer for processing; electronically receive, based at least in response to the electronic prior authorization request, an electronic prior authorization response from the pharmacy claims processor computer
Validating and correcting data field formats with user prompt
determine, for at least a portion of the plurality of data fields, a format for the data; compare the format of the data to a required format; determine, based at least on the comparison, if the format of the data in at least one of the data fields is different from the required format; in an instance in which at least one of the format of the data is determined to be different: (a) modify the format to match the required format, and (b) prompt the user to review and accept the modified format, wherein required data fields comprise data fields necessary to establish prior authorization and wherein the format comprises at least one of a data character length or a data character type
Inserting non-insurance based patient financial assistance message into the response
identify a medication identifier in the electronic prior authorization response; determine, based at least on the medication identifier, a non-insurance based patient financial assistance opportunity that reduces or eliminates patient financial responsibility for the medication; retrieve a non-insurance based patient financial assistance opportunity message associated with the determined opportunity; insert the non-insurance based patient financial opportunity assistance message into the electronic prior authorization response; electronically direct communication of the electronic prior authorization response and the non-insurance based patient financial assistance opportunity message for receipt by the prescriber computer
Computer-implemented method version of the same workflow for service provider computer
electronically receiving, by a service provider computer, an electronic prior authorization request; identifying the request type identifier; determining evaluation parameters and required data fields; evaluating required data fields; in response to missing required data, adding a data element from an associated EHR field and prompting user acceptance or prompting for manual addition; electronically transmitting the request to a pharmacy claims processor for processing; electronically receiving an electronic prior authorization response; determining and comparing data formats to required formats and modifying format when different with user acceptance; identifying a medication identifier; determining a non-insurance based patient financial assistance opportunity; retrieving a non-insurance based patient financial assistance message; inserting the message into the electronic prior authorization response; and electronically transmitting the response and message for receipt by the prescriber computer
Across the independent claims, the core inventive coverage is the combination of request-type driven identification of evaluation parameters and required data fields, evaluation with conditional EHR-based population of missing required data and/or prompting for manual addition, data-format comparison with conditional modification and user acceptance, forwarding to a pharmacy claims processor and receiving a prior authorization response, and insertion of a non-insurance based patient financial assistance opportunity message into the response based on a medication identifier.
Stated Advantages
reduces or eliminates a patient financial responsibility for the medication identified by the medication identifier
Documented Applications
providing prescription prior authorization between a prescriber and a pharmacist
electronically transmitting and receiving electronic prior authorization requests/responses for processing by a pharmacy claims processor computer and receipt by the prescriber computer
inserting a non-insurance based patient financial assistance opportunity message into an electronic prior authorization response for receipt by the prescriber computer
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