Abstract: Systems and methods are disclosed for settling health care claims as part of a claim adjudication process. A standard financial transaction network is used to settle the portion of the claim not covered by insurance. Eligibility checks are also disclosed that make use of the financial transaction network to determine whether a patient has sufficient funds in a financial account to cover his portion of health care related expenses. The eligibility checks can be combined with the settlement process.

Abstract: Transaction network operators can facilitate transactions of healthcare related goods via customers' tax-advantaged accounts, but without subjecting themselves to privacy regulations. Authorization for healthcare related purchases, including both price information and product information, is passed over PBM networks or other networks that already are regulation-compliant, while other purchase requests pass over existing payment card transaction networks. The PBM network divorces product information from the payment information, confirms eligibility, and passes the payment information to the general transaction network operator, indicating those funds are to come from the customer's tax-advantaged account. The network operator marries the payment information from the PBM with the other transaction information from the payment card network, withdraws appropriate funds from the tax-advantaged account, and notifies the merchant the amount that has been withdrawn from the tax-advantaged account.