Abstract: Systems and methods for identifying healthcare transactions with a risk of failing to include appropriate directions for use are provided. A healthcare claim transaction may be received from a healthcare provider computer. Based upon an analysis of the received healthcare claim transaction, identification information for a prescriber may be determined. A determination may be made as to whether the identified prescriber is an at-risk prescriber that has previously failed to include appropriate directions for use in association with a prescription. If it is determined that the prescriber is an at-risk prescriber, then a predetermined control action may be implemented. Otherwise, if it is determined that the prescriber is not an at-risk prescriber, then the healthcare claim transaction may be communicated to a claims processor computer associated with a claims processor.

Abstract: Systems and methods are provided for generating edits for healthcare transactions to address billing discrepancies. Information associated with an audit performed on a healthcare transaction may be received. Based at least in part on the received information, a billing discrepancy associated with the healthcare transaction may be identified. Based upon the identified billing discrepancy, a proposed edit may be generated that can be utilized to mitigate an impact of the identified billing discrepancy during the processing of one or more subsequent healthcare transactions.

Abstract: Systems and methods are provided for supporting and validating patient enrollment in one or more healthcare programs. The systems and methods may include receiving a prescription claim request from a pharmacy computer, where the prescription claim request includes at least (i) a first product identifier identifying with a prescribed product for a patient, and (ii) patient information associated with the patient; determining, based at least in part upon the first identifier, that patient is subject to a requirement to enroll in one or more required healthcare programs prior to the prescription product being released to the patient; extracting enrollment information from the prescription claim request, the extracted enrollment information including at least a portion of the patient information from the prescription claim request; and automatically utilizing the extracted enrollment information to complete at least a portion of an enrollment process for the one or more required healthcare programs.

Abstract: Systems and methods are provided for the coordination of benefits. The systems and methods may include receiving a healthcare claim request from a healthcare provider computer; determining, based at least in part from patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer; generating a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer; and generating a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply associated with the primary claim request, the COB claim request, the COB claim request associated with a second payer.

Abstract: Computer systems and methods for: (A) identifying a leader within the context of an online game, the leader being associated with at least one follower within the context of the game; (B) determining one or more leadership metrics regarding the leader's effectiveness in enhancing a gaming experience of the at least one follower in playing the game; (C) determining, based at least in part on the one or more leadership metrics, an amount of compensation to award to the leader; and (D) communicating the amount of compensation to the leader and/or facilitating payment of the compensation to the leader. Suitable leadership metrics may be, for example: (A) the amount of revenue generated from the leader's followers; (B) the followers' rating of the leader; or (C) the length of time that the leader's followers subscribe to the game.