Abstract: A method is disclosed whereby consumers enrolled in a prescription benefit plan can obtain prescription medication fulfillment at any participating pharmacy of their choice, regardless of whether the fulfillment is by a retail pharmacy or a mail order pharmacy, and whether the quantity of medication prescribed is for administration over a short period (acute care) or a prolonged period (maintenance). The plan of this invention operates by having the plan manager substantially equalize the financial effects of the discounts and services fees allowed to participating pharmacies such that both retail and mail order pharmacies are compensated in a manner which encourages them to accept all consumers and fill all prescriptions. Compensation is preferably adjusted periodically by the manager to retain pharmacy incentives. Consumers obtain choice of pharmacies, plan payers have pleased employees and members and pharmacies obtain income from the entire spectrum of consumers.

Abstract: A method for electronically determining patient medical treatment eligibility, coverage, copayment amount and insurer billing simultaneously, by: (a) a patient requesting medical treatment at a retail clinic; (b) the patient presenting a health insurance card at the retail clinic; (c) the retail clinic transmitting patient health insurance card information to a centralized adjudication facility; (d) the retail clinic transmitting medical treatment information to the centralized adjudication facility; (e) the centralized adjudication facility determining patient medical treatment coverage, eligibility and copayment amount (f) transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic; (g) the patient purchasing the medical treatment by paying the retail clinic the copayment amount, (h) transmitting a bill to the health care insurance provider; and (i) thereby informing the retail clinic clinician to sell the medical trea

Abstract: Automated conversion of incompatible data files into compatible benefit packages for a pharmacy benefit management (PBM) platform. In an embodiment, client files, comprising representations of benefit plans, are received. Each representation comprises a plurality of field values. For each representation, a layout and a set of translation rules are received, the plurality of field values in the representation are mapped to a plurality of attribute values based on the layout, and a benefit package, comprising a plurality of components, is generated by applying the set of translation rules to the plurality of attribute values, such that the benefit package represents the benefit plan.

Abstract: A method for electronically determining patient medical treatment eligibility, coverage, copayment amount and insurer billing, by: (a) a patient requesting medical treatment at a retail clinic; (b) the patient presenting a health insurance card at the retail clinic; (c) the retail clinic transmitting patient health insurance card information to a centralized adjudication facility; (d) the retail clinic transmitting medical treatment information to the centralized adjudication facility; (e) the centralized adjudication facility determining patient medical treatment coverage, eligibility and copayment amount (f) transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic; (g) the patient purchasing the medical treatment by paying the retail clinic the copayment amount, (h) transmitting a bill to the health care insurance provider; and (i) thereby informing the retail clinic clinician to sell the medical treatment to the pa

Abstract: Automated conversion of incompatible data files into compatible benefit packages for a pharmacy benefit management (PBM) platform. In an embodiment, client files, comprising representations of benefit plans, are received. Each representation comprises a plurality of field values. For each representation, a layout and a set of translation rules are received, the plurality of field values in the representation are mapped to a plurality of attribute values based on the layout, and a benefit package, comprising a plurality of components, is generated by applying the set of translation rules to the plurality of attribute values, such that the benefit package represents the benefit plan.

Abstract: A method for electronically determining patient medical treatment eligibility, coverage, copayment amount and insurer billing, by: (a) a patient requesting medical treatment at a retail clinic; (b) the patient presenting a health insurance card at the retail clinic; (c) the retail clinic transmitting patient health insurance card information to a centralized adjudication facility; (d) the retail clinic transmitting medical treatment information to the centralized adjudication facility; (e) the centralized adjudication facility determining patient medical treatment coverage, eligibility and copayment amount (f) transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic; (g) the patient purchasing the medical treatment by paying the retail clinic the copayment amount, (h) transmitting a bill to the health care insurance provider; and (i) thereby informing the retail clinic clinician to sell the medical treatment to the pa

Abstract: The system includes a variety of aspects which allow users to efficiently receive reimbursement for claims. Claims accepted by CMS result in reimbursement for claimants. Claims rejected by CMS represent lost revenue for claimants. In order to maximize accepted claims and minimize rejected claims, the system provides for the generation of more accurate PDE files for submission and for the accumulation and formatting of information received from CMS to facilitate correction of PDE errors. These aspects work in tandem to minimize lost revenue for the claimant. Further, aspects described herein help minimize PDE error rates. Such minimization of errors can affect the reputation, business model, credibility, and competitive posture of Part D plan sponsors. Accordingly, minimization of PDE error rates is important to the overall design, function, and profitability of any Medicare Part D plan sponsor.

Abstract: Systems for filling and managing a patient's healthcare needs are provided. Some systems and methods described herein relate to a total healthcare fulfillment system. The healthcare fulfillment system of various embodiments is a central portal which coordinates with multiple parties, for example, with physicians, retail pharmacies, mail-order pharmacies, specialty providers, and patients in order to address all of a patient's prescription drug needs or other healthcare needs.

Abstract: Systems and techniques are disclosed for determining an intervention for a patient based at least in part on a likelihood of the patient to adhere to a prescription. In some implementations, a patient profile for a patient is obtained from one or more computer-readable storage devices in a patient population, the patient profile including multiple patient attributes; an adherence score is obtained for the patient profile, the adherence score for predicting patient adherence based on one or more of the multiple patient attributes wherein the adherence score indicates a likelihood of adherence of the patient to a prescribed treatment; and the adherence score obtained for the patient profile is modified into a modified score for intervention based on a set of weights for weighting the patient attributes.

Abstract: Systems for filling and managing a patient's healthcare needs are provided. Some systems and methods described herein relate to a total healthcare fulfillment system. The healthcare fulfillment system of various embodiments is a central portal which coordinates with physicians, retail pharmacies, mail-order pharmacies, specialty providers, and patients in order to address all of a patient's prescription drug needs or other healthcare needs.

Abstract: A healthcare mass customization infrastructure individualizes plan designs by incorporating demographics, income, drug history, medical history, lab values, and future genomic information for appropriate and affordable access to medications. The mass customization infrastructure results in quality outcomes for the patients, improved care and productivity for the providers, and lower medical costs for the payers.

Abstract: A method of operating a health care needs fulfillment system, by: (a) a PBM contracting with a plurality of health care suppliers to fulfill a plurality of health care needs requests; (b) end users sending individual health care needs requests to the PBM; (c) the PBM selecting the health care suppliers to supply each of the end users' individual health care needs requests; and (d) the PBM alerting the selected health care suppliers to fulfill the end users' individual health care needs requests.

Abstract: A dynamic claims adjudication system is provided that implements a dynamic claims adjudication process to provide flexible determination of the adjudication rule set to be used to adjudicate a claim for a particular prescription drug regardless of the mandates of the formulary and the rigidity of the tier into which the drug is placed on the formulary. The claims adjudication system and corresponding methods dynamically determine the adjudication rule set to be used to adjudicate a claim based on an analysis of criteria and identification of a tier changing criteria. Accordingly, the rigidity of conventional formulary based claims adjudication is eliminated in favor of dynamic and flexible real time claims adjudication.

Abstract: Systems and methods for proactively identifying impacts and making recommendations regarding modifications to a drug formulary are provided. In an embodiment, a proposed modification to a formulary is received. One or more data sources are accessed, and an impact of the proposed modification to the formulary is determined based on the one or more data sources. The impact of the proposed modification is then provided to a user prior to implementation of the proposed modification.

Abstract: Systems and methods for generating and managing a hybrid formulary for claims adjudication. In an embodiment, a plurality of source formulary components are received. Each of the plurality of source formulary components comprises one or more drug entries and/or one or more utilization management rules. A configuration is also received. The configuration comprises a plurality of component identifiers and one or more hierarchy rules. Each of the plurality of component identifiers identifies one of the plurality of source formulary components. The one or more hierarchy rules are applied to the identified source formulary components to generate a hybrid formulary. The hybrid formulary comprises a plurality of drug entries and/or one or more utilization management rules, which can be used for claims adjudications, reporting, or any other downstream formulary application.

Abstract: Systems, methods and devices for modifying a patient adherence score which include, in one implementation, obtaining a patient profile in a patient population, the patient profile including multiple patient attributes and each patient attribute including a value; obtaining an adherence score for the patient profile for predicting patient adherence based on one or more of the multiple patient attributes wherein the adherence score indicates a likelihood of adherence of the patient to the prescribed treatment; and applying a modifier associated with an application to modify the adherence score obtained for the patient profile into a modified score for the application.

Abstract: Systems and methods for overriding claim denials and approvals are provided that determine that a current claim will be denied and search the purchasing member's claim history for previously approved claims that match the current claim. If a matching claim is found and is dated within a certain predetermined window of time, the current claim is approved. Additionally, when it is determined that a current claim will be approved at a high tier level the member's claim history is searched for a previously approved claim that matches the current claim and a formulary crosswalk analysis is performed. If a matching claim with a lower tier level is found in the member's claim history or the crosswalk analysis determines that a lower tier level is available, the current claim is processed using the lower tier. Claims overridden are digitally stamped for reporting purposes and for subsequent claim matching.

Abstract: A method of processing drug claims, by: (a) receiving a claim; (b) sorting the claim for processing by determining which processed drug list the claim belongs with; and then (c) processing the claim according to the particular processed drug list to which the claim belongs. A hierarchy of drug lists are used in a preferred order. If the drug is found on the first drug list, the system then moves directly to the processing stage. However, if the drug is not found on the first list, the system checks whether the drug is on the second drug list. If the drug is found on the second drug list, the system then moves directly to the processing stage, etc.

Abstract: System and techniques are disclosed for determining a recommended prescription. In some examples, a recommended prescription can be determined by obtaining a behavior prediction score for a patient, wherein the behavior prediction score is based at least in part on a likelihood of adherence of the patient to a prescribed treatment; and determining a recommended prescription, from various previously provided prescriptions, based on the behavior prediction score and prescription scores of the various previously provided prescriptions; and providing the recommended prescription for display. The prescription scores can indicate a likely effect of the various previously provided prescriptions on adherence.

Abstract: Systems and techniques are disclosed for determining a health risk assessment score for a patient who did not complete a health risk assessment. In some implementations, the health risk assessment score can be determined for the patient who did not respond based on a behavior prediction score obtained for the patient who did not respond, behavior prediction scores for patients who did respond to the health risk assessment, and health risk assessment scores for the patients who did respond.