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: Systems, methods, and computer-readable media are provided for determining patient eligibility for one or more types of sponsored healthcare services and providing notifications thereof. An example healthcare service is high-risk medication monitoring. A program sponsor may provide an indication of a high-risk prescription drug in connection with which a patient may be eligible for medication monitoring. The program sponsor may also provide an indication of an alternative prescription drug that may be used for treating the same health condition for which the high-risk drug is used. Upon receipt of a healthcare claim transaction that includes a claims processor identifier associated with program sponsor and a prescription drug identifier that identifies the high-risk drug, a number of one or more prior healthcare claim transactions corresponding to dispensing of the high-risk drug to the same patient may be determined.

Abstract: Systems, methods, and computer-readable media are provided for determining patient eligibility for one or more types of sponsored healthcare services and providing notifications thereof. Healthcare claim transaction data may be received from a healthcare provider computer on behalf of a healthcare provider. The healthcare claim transaction data may be determined to satisfy one or more eligibility parameters specified by a healthcare service sponsor for determining a patient's eligibility for a healthcare service. An eligibility data record may be generated indicating the patient's eligibility for the healthcare service. A subsequent healthcare claim transaction may trigger generation and transmission of an eligibility notification message to a healthcare provider. The eligibility notification message may indicate eligibility of the patient for the healthcare service.

Abstract: Systems and methods are provided for verifying correlation of diagnosis and medication as part of qualifying program eligibility verification for a medication requested in a healthcare transaction. A service provider computer may receive an ADT transaction from a covered entity healthcare provider that includes patient identifiers identifying a patient and a diagnosis code identifying a malady affecting a the patient. The service provider computer may receive a healthcare claim transaction from a pharmacy requesting a medication for the patient. The service provider computer can verify that the requested medication is one typically used for the malady identified by the diagnosis code. The service provider computer may also determine whether the requested medication is eligible under a predefined qualifying program based at least in part on the healthcare claim transaction and patient and/or prescriber registration information.