Interested in licensing this patent?
MTEC can help explore whether this patent might be available for licensing for your application.
Publication Number
US-11514137-B1
Publication Date
2022-11-29
Expiration Date
Abstract
An improved alternative therapy identification system increases the efficiency for obtaining information for alternative therapies. The alternative therapy identification system automates alternative therapy identification information from both a product level and a drug cost level. The improved alternative therapy identification system may also increase the efficiency by improving alternative therapy selection to occur at the prescriber level.
Core Innovation
An improved alternative therapy identification system automates alternative-therapy selection for a prescriber in real-time or near real time. A healthcare provider sends a prescription benefit check request to a service provider computer, which routes the request to a pharmacy claims processor computer via a routing table identifying a destination of communications. The system receives a prescription response with approval or denial status and a patient pay amount for the prescribed medication, and it also processes an alternative therapy response including an approved or denied status and an alternative therapy patient pay amount.
The system stores alternative therapy tables in a first predefined format, and each alternative therapy table includes a therapeutic class, one or more product identifiers, and a product cost corresponding to each product identifier. The system parses the prescription benefit request to generate a prescription identifier in a standardized format compatible with the first predefined format of the alternative therapy tables, and it automatically searches the alternative therapy tables based upon the prescribed medication.
Based at least upon the identifier for the prescribed medication and the product cost for one or more product identifiers of the same therapeutic class, the system identifies an alternative product equivalent to the prescribed medication. The system automatically generates a second prescription benefit request in the different predefined format received, where the second prescription benefit request is compatible with the pharmacy claims processor computer and includes information from the alternative therapy tables with an identifier for the alternative product.
Without pharmacy or patient interaction, the system automatically transmits a prescription benefit response based upon the routing table. The transmitted prescription benefit response includes the prescription response including at least the patient pay amount for the prescribed medication and the alternative therapy response including at least the patient pay amount for the alternative product.
Claims Coverage
Independent claim clm-00001 covers a real-time or near real-time system that parses a prescription benefit request into a standardized identifier, searches alternative therapy tables to identify an alternative product equivalent, generates a second benefit request compatible with a pharmacy claims processor, and automatically transmits a combined prescription benefit response using a routing table. Across the family summary, multiple inventive features add constraints for payment thresholds, denial detection, therapeutic-class-based equivalence, reversal request generation, and alternative therapy response data integration.
Routing-table driven transmission of pharmacy claims communications
Storing a data file storing a routing table identifying a destination of communications received from a pharmacy claims processor computer and automatically transmitting a prescription benefit response based upon the routing table without pharmacy or patient interaction.
Standardized parsing of prescription benefit requests
Receiving a prescription benefit request in a different predefined format comprising patient data, patient pharmacy benefit data, an identifier for a prescribed medication, and prescriber data, and parsing the prescription benefit request to generate a prescription identifier in a standardized format compatible with the alternative therapy tables.
Alternative therapy table search and equivalent product identification
Accessing pharmacy data stored in one or more alternative therapy tables in real-time or near real time, automatically searching the alternative therapy tables based upon the prescribed medication, and identifying an alternative product equivalent to the prescribed medication based at least upon the identifier and the product cost for product identifiers of the same therapeutic class.
Generation of a second compatible benefit request for an alternative product
Automatically generating a second prescription benefit request in the different predefined format received, such that the second prescription benefit request is compatible with the pharmacy claims processor computer, wherein generating the second prescription benefit request comprises generating a benefit request based upon the prescribed medication and generating a benefit request based upon the identified alternative product equivalent, including information from the alternative therapy tables including an identifier for the alternative product.
Integrated handling of prescription and alternative therapy responses
Receiving, from the pharmacy claims processor computer, a prescription response and an alternative therapy response in response to transmission of the benefit request based upon the prescribed medication and the benefit request based upon the identified alternative product, where the prescription response comprises at least a patient pay amount and a response status indicating denial or approval, and where the alternative therapy response comprises at least an approved status or a denied status and an alternative therapy patient pay amount.
The independent claim’s inventive coverage centers on real-time or near-real-time parsing of a prescription benefit request, searching alternative therapy tables by therapeutic class and product cost to identify an alternative product equivalent, generating a second compatible benefit request for that alternative, and automatically transmitting a combined prescription benefit response including prescription and alternative product patient pay amounts based on routing-table information without pharmacy or patient interaction.
Stated Advantages
Automates alternative-therapy identification and selection for a prescriber in real-time or near real time.
Provides alternative therapy information including patient pay amounts based on approval or denial statuses.
Operates without pharmacy or patient interaction.
Documented Applications
Alternative therapy identification for a prescriber by automated selection of an alternative product equivalent during a prescription benefit check workflow.
Interested in licensing this patent?