Abstract: Systems and methods may provide notifications of availability of generic drugs or products. The systems and methods may include receiving, from a healthcare provider computer, a healthcare claim transaction request that identifies a product for a patient; determining that the product identified by the healthcare claim transaction request is a non-generic product or a branded product; determining that a generic equivalent for the product identified by the healthcare claim transaction request will become available on a future date; generating a generic notification message indicating the availability of generic equivalent for the product on the future date; and delivering or directing a delivery of the generic notification message.

Abstract: Systems and methods are provided for processing healthcare claim transactions that are rejected due to a host error. The systems and methods may be carried out by a suitable service provider. A healthcare claim transaction received from a healthcare provider computer may be routed to a claims processor computer. A determination may be made that the healthcare claim transaction has not been approved as a result of a host processor error associated with the claims processor computer. Based at least in part on the determination, the healthcare claim transaction may be resubmitted to the claims processor computer.

Abstract: Systems and methods for evaluating healthcare claim transactions for Medicare eligibility are described. A healthcare claim transaction designating a payor other than a Medicare Part B payor may be received from a healthcare provider computer, and a product or service associated with the transaction may be identified as a product or service that is eligible for Medicare Part B coverage. Based at least in part on the identification, a determination may be made as to whether a patient associated with the transaction is eligible for Medicare Part B coverage. The transaction may be routed to a claims processor computer if it is determined that the patient is not eligible for Medicare Part B coverage. However, if it is determined that the patient is eligible for Medicare Part B coverage, then a message indicating that the transaction is rejected may be communicated to the healthcare provider computer.

Abstract: Systems and methods for monitoring controlled substance distribution include receiving a healthcare transaction at a service provider computer. The healthcare transaction may be parsed to determine the healthcare provider submitting the healthcare transaction, the drug being prescribed as part of the healthcare transaction and the class of controlled substance to which the drug being prescribed belongs. Counters associated with total scripts prescribed by the healthcare provider and the class of controlled substance may be incremented upward in view of the healthcare transaction being approved by a claims processor. A current percentage of the class of controlled substances being prescribed can be calculated for the healthcare provider and compared to a threshold percentage for the particular class of controlled substance. If the current percentage violates the threshold percentage, a notification can be sent to a corporate level or management level for the healthcare provider for review.

Abstract: Systems and methods are provided for overriding rejections of healthcare claim transactions. A healthcare claim transaction is received by a service provider from a healthcare provider computer and at least one edit is performed on the healthcare claim transaction. A rejection for the healthcare claim transaction is identified based at least in part on the at least one edit, and a message comprising an indication of the rejection is communicated to the healthcare provider computer. A reason for overriding the edit is received at an edit override web server from the healthcare provider computer, and override information for the rejection is generated based at least in part on the receipt of the override reason. The healthcare claim transaction is then reprocessed, and the generate override information is utilized to suppress the at least one edit during the reprocessing of the healthcare claim transaction.

Abstract: Systems and methods for processing rejected healthcare claim transactions for over-the-counter (“OTC”) products are provided. A healthcare claim transaction associated with a product requested by a customer may be received from a healthcare provider computer. The healthcare claim transaction may be communicated to a claims processor for adjudication, and a denied claim response for the healthcare claim transaction may be received from the claims processor. Based at least in part upon a classification of the product, the denied claim response may be converted to an approved claim response, and the approved claim response may be communicated to the healthcare provider computer. In certain embodiments, the above operations may be performed by one or more computers associated with a service provider.

Abstract: Systems and methods for the coordination of benefits in healthcare claim transactions are provided. A healthcare claim request including information associated with a plurality of prescription claims for a single healthcare transaction may be received from a healthcare provider computer and identified as a bundled healthcare claim request. A primary claim request for the healthcare transaction may be generated and communicated to a first claims processor computer for adjudication, and a first adjudicated reply may be received from the first claims processor computer. Based at least in part on the received first adjudicated reply, a secondary claim request for the healthcare transaction may be generated and communicated to a second claims processor computer for adjudication. A second adjudicated reply may be received from the second claims processor, and information associated with the first adjudicated reply and the second adjudicated reply may be communicated to the healthcare provider computer.

Abstract: Systems and methods are provided for the identification of available payers for healthcare transactions. A reply to a healthcare claim transaction may be received from a claims processor computer. Based at least in part on the reply, a determination may be made that the healthcare claim transaction has been rejected for an eligibility reason. An available payer for a patient associated with the received reply may be identified subsequent to the determination. Information associated with the identified available payer may be communicated to a healthcare provider associated with the healthcare claim transaction.

Abstract: Systems and methods are provided for generating payor sheets associated with payors for healthcare transactions. Information associated with one or more healthcare transactions that have been processed by a payor may be obtained. A plurality of data fields included in the one or more healthcare transactions may be identified, and a respective usage of each of the identified data fields within the one or more healthcare transactions may be calculated. Based upon the calculated usages, one or more of the plurality of data fields may be identified as required fields. A required field may be a field required by the payor during the submission of a healthcare transaction. Based at least in part upon the identified one or more required fields, a payor sheet associated with the payor may be generated.

Abstract: Systems and methods may be provided for alternate pricing. The systems and methods may include receiving first information associated with a first claim transaction, where the first information identifies a first drug, a first quantity of the first drug, and a first price for the first drug, determining a first product classification for the identified first drug, where the first product classification indicates that the identified first drug is a preferred drug, and updating an alternate pricing database with the first price for the first drug. The systems and methods may also include utilizing the alternate database to identify one or more lower-cost alternate drugs that are therapeutic alternatives for a requested drug. Customers may be provided with information regarding the identified lower-cost alternate drugs.

Abstract: Systems and methods are provided for verification of claims submitted by one or more pharmacies. The systems and methods include storing a Multiple Package Edit (MPE) table that includes drug package size information, storing an audit table that includes drug dose information, and storing a user table that includes pharmacy-supplied drug information. The systems and methods also include receiving a first claim submission from a pharmacy computer, where the first claim submission includes at least one identifier, a quantity, and days supply for a requested drug. The systems and methods further include determining that the first claim submission includes an error in at least one of the quantity and days supply based upon information obtained from at least one of the user table, the MPE table, and the audit table, and messaging the pharmacy computer with an indication of the determined error.

Abstract: Systems and methods are provided for verification of claims submitted by one or more pharmacies. The systems and methods include storing a Multiple Package Edit (MPE) table that includes drug package size information, storing an audit table that includes drug dose information, and storing a user table that includes pharmacy-supplied drug information. The systems and methods also include receiving a first claim submission from a pharmacy computer, where the first claim submission includes at least one identifier, a quantity, and days supply for a requested drug. The systems and methods further include determining that the first claim submission includes an error in at least one of the quantity and days supply based upon information obtained from at least one of the user table, the MPE table, and the audit table, and messaging the pharmacy computer with an indication of the determined error.