Abstract: A computing device, method and computer program product are provided to automatically reverse an action indicated by an electronic message. In relation to a method, an electronic message is parsed to separately identify a plurality of fields of the electronic message providing different types of information. The method constructs a response to the electronic message that reverses the action indicated by the electronic message and transmits the response to the electronic message to a request processor that provided the electronic message. The method constructs an alternative message that provides an alternative action to the action indicated by the electronic message and transmits the alternative message to a source. In response to the alternative message, the method receives a subsequent request from the source. If the alternative action is to be taken, the method processes the subsequent request in a different manner than the request that generated the electronic message.

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.

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.

Abstract: A computing device, method and computer program product are provided to process messages received from a source and to construct messages transmitted to a recipient that include the information required to elicit the desired response. In relation to a method, an electronic message is received and analyzed relative to requirements of the related message to determine whether the electronic message includes information required by the related message.

Abstract: Embodiments are disclosed for improved data modeling in a relational database management system. In the context of a method, an example embodiment includes ingesting, by data ingestion circuitry, one or more records into one or more stage tables in a staging layer. This example embodiment further includes generating, by data modeling circuitry, a data alignment table defining a unique set of data fields, and generating, by the data modeling circuitry and using the one or more stage tables and the data alignment table, a key mapping table identifying correspondences between data fields in the one or more stage tables and data fields in the data alignment table. Corresponding apparatuses and computer program products are also provided.

Abstract: The evaluation system provides a real-time mechanism for auditing purchase request transactions prior to the purchase being completed in order to determine if one or more audit parameters are violated and the transaction should not be completed. An electronic product request can be received from a merchant of the product. The request can identify at least the merchant, the party, and the product requested for purchase. One or more business rules and auditing parameters for auditing the request can be identified based on the identity of the merchant. The contents of the request can then be audited to determine if the request satisfies the audit parameters. The contents of the request can also be used to identify historical transactions for the party, which can be used to determine if the current request violates one or more of the audit parameters.

Abstract: A healthcare claim transaction may be received by a service provider computer from a pharmacy computer. An intervention service for a patient may be identified and the screening parameters to be obtained from the patient for the intervention service may be identified. The service provider computer may generate a reject response and insert a reject code and/or message notifying the pharmacy of the first screening parameter to obtain from the patient. The rejection response may be sent to the pharmacy computer, which may subsequently send a resubmitted healthcare claim transaction that includes the requested first screening parameter data for the patient. The service provider computer may parse the transaction to identify the data. The iterative process may continue until all of the screening parameter data for the patient is received by the service provider computer, which may transmit that data to a claims processor computer.

Abstract: A database system, computing device and method are provided to construct and process messages in a manner dependent upon the satisfaction of predefined requirements. In regards to a method, an electronic message is received and a determination is made as to whether the subject of the electronic message is a member of a group for which the predefined requirements are to be satisfied. If so, the method determines whether the predefined requirements are satisfied with respect to the subject of the electronic message. The method also constructs a related message, causes the related message to be transmitted to a request processor and receives a response from the request processor. The method then constructs a response to the electronic message and, in an instance in which the predefined requirements are not satisfied, causes a notification regarding a failure to satisfy the predefined requirements to also be constructed.

Abstract: Systems and methods are provided for determining patient adherence to a medication protocol by evaluating healthcare transactions. An e-prescription transaction can be received from a prescriber and evaluated to determine if the patient is to receive adherence analysis. If so, the e-prescription data can be stored and the e-prescription can be forwarded to a pharmacy. A healthcare claim transaction for a medication can be received from the pharmacy and forwarded on for adjudication. If approved, the claim transaction data can be evaluated to determine if it matches any stored e-prescription data records. Upon identifying a match, a prescription fill status notification can be generated and transmitted to the prescriber computer associated with the prescriber of the medication in the e-prescription. If the healthcare claim transaction is for a refill or a maintenance medication, a patient adherence level can be calculated and included in the prescription fill status notification.

Abstract: A computing device, method and computer program product are provided to process messages received from a source and to construct messages transmitted to a recipient that include the information required to elicit the desired response. In relation to a method, an electronic message is received and analyzed relative to requirements of the related message to determine whether the electronic message includes information required by the related message.

Abstract: An improved adherence monitoring system increases the efficiency for obtaining patient adherence information. The improved adherence monitoring system reduces network traffic with regards to the communication of patient adherence information. The improved adherence monitoring system automates an adherence notification pathway. The improved adherence monitoring system can increase patient adherence by increasing the efficiency of medication therapy. The improved adherence monitoring system may also increase the efficiency by which patient adherence information is disbursed.

Abstract: An adjudicated prescription claim transaction response is received and includes a total amount paid by the claims processor, a patient pay amount, and the pharmacy's Usual and Customary Charge amount for a product/service. The adjudicated response can be evaluated to determine it was approved/paid and the total amount paid by the claims processor is zero or less. An income audit evaluation may be conducted by comparing the patient pay amount to the Usual and Customary Charge amount. Based on the Usual and Customary Charge amount being less than or less than or equal to the patient pay amount, a reversal transaction can be generated and transmitted to a claims processor computer for adjudication. Further, the adjudicated prescription claim transaction response can be converted from an approved/paid response to (or replaced by) a rejected adjudicated prescription claim transaction response and transmitted to the pharmacy computer that initiated the prescription claim transaction.

Abstract: An improved medical delivery system increases the efficiency of acquiring and delivery savings to patients. The improved medical delivery system can reduce the potential for a pharmacy to fail to capture a financial benefit that may be available to the patient. The improved medical delivery system can provide a pharmacy improved systems for capturing patient financial benefits during a typical workflow process, and route the savings to the patient. The improved medical delivery system can also reduce the resources necessary for a pharmacy to acquire and provide a financial benefit to a patient.

Abstract: A computing device, method and computer program product are provided to qualify an instruction based upon the input site of the instruction. In the context of a computing device, the computing device includes data field analysis circuitry to analyze data fields representing a respective instruction that has been received to determine a data field that defines the input site of the respective instruction. The computing device also includes data field comparison circuitry to compare the data field that defines the input site to an eligible input site inclusion listing to determine whether the input site of the instruction is included. The computing device also includes qualification test circuitry to perform one or more additional qualification tests and instruction qualification circuitry to qualify the instruction when the input site is included within the eligible input site inclusion listing and in which the one or more additional qualification tests are satisfied.

Abstract: Systems and methods are provided for determining and communicating patient incentive information to a prescriber. The patient incentive information may adjust the patient copay amount for a prescribed medication. The patient incentive information may be determined by evaluating pharmacy identification information and medication identifiers in a received prescription benefit check transaction and/or adjudicated response to a healthcare transaction to determine if an incentive is available to be applied to the current transaction. The incentive amount may be retrieved and the patient copay amount in the adjudicated response may be amended prior to transmitting the adjudicated response to the prescriber of the medication.

Abstract: Systems and methods are provided for determining and communicating prescription benefit coverage information to a prescriber of the product, service, or medication. A prescription benefit check request may be received by the service provider computer from a healthcare provider computer for the prescriber of the product, service, or medication. The service provider computer may format a prescription request for the prescribed product, service, or medication and transmit the prescription request to a pharmacy claims processor computer for processing. The service provider computer may receive a prescription response that includes a determination of the prescription request from the pharmacy claims processor computer.

Abstract: Embodiments are disclosed for utilizing an efficient database architecture while facilitating query flexibility. An example method includes generating, by data modeling circuitry of a database system, a database comprising a set of dimension tables and a hybrid fact table, wherein each hybrid fact table record identifies corresponding records in the set of dimension tables that specify (i) current values of the one or more attributes corresponding to the hybrid fact table record and (ii) records comprising historical values of the one or more attributes corresponding to the hybrid fact table record that were current at the time of creation of the hybrid fact table record. The example method further includes receiving a query, and generating and transmitting a response to the received query. Corresponding apparatuses and computer program products are also provided.

Abstract: Systems and methods are provided for determining eligibility in a prescription safety network program, such as a risk evaluation and mitigation strategies (REMS) program. Enrollment information can be received from a prescriber of medication, such as a doctor, to enroll in a prescription safety network program. The prescriber enrollment information can be stored in a first database and the prescriber can be provided the ability to enroll patients in the prescription safety network program in a second database that is separate and distinct from the first database. Patient enrollment data for the prescription safety network program can be received from the prescriber and stored in the second database. Further, pharmacy/pharmacist enrollment data for the prescription safety network program can be received from a pharmacy/pharmacist and stored in the second database.

Abstract: Systems and methods are provided for determining and communicating patient incentive information to a prescriber. The patient incentive information may adjust the patient copay amount for a prescribed medication. The patient incentive information may be determined by evaluating pharmacy identification information and medication identifiers in a received prescription benefit check transaction and/or adjudicated response to a healthcare transaction to determine if an incentive is available to be applied to the current transaction. The incentive amount may be retrieved and the patient copay amount in the adjudicated response may be amended prior to transmitting the adjudicated response to the prescriber of the medication.

Abstract: Systems and methods are provided for determining and communicating intervention service opportunities, such as medication therapy management services, that may be available for a patient, as part of processing a healthcare claim transaction. A healthcare claim transaction, such as a prescription benefit request transaction, may be received by the service provider computer from a healthcare provider computer. The service provider computer may determine if an intervention service is available for the patient and if an available intervention service notification has been transmitted to the pharmacy computer prior to the service provider computer receiving the healthcare claim transaction. The service provider computer may receive an approved adjudicated response and generate a patient intervention service form corresponding to the available intervention service for the patient.