Abstract: An adjudicated prescription claim transaction response is received and includes a total amount paid by the claims processor, a patient pay amount, and the pharmacy's Usual and Customary Charge amount for a product/service. The adjudicated response can be evaluated to determine it was approved/paid and the total amount paid by the claims processor is zero or less. An income audit evaluation may be conducted by comparing the patient pay amount to the Usual and Customary Charge amount. Based on the Usual and Customary Charge amount being less than or less than or equal to the patient pay amount, a reversal transaction can be generated and transmitted to a claims processor computer for adjudication. Further, the adjudicated prescription claim transaction response can be converted from an approved/paid response to (or replaced by) a rejected adjudicated prescription claim transaction response and transmitted to the pharmacy computer that initiated the prescription claim transaction.

Abstract: The evaluation system provides a real-time mechanism for auditing purchase request transactions prior to the purchase being completed in order to determine if one or more audit parameters are violated and the transaction should not be completed. An electronic product request can be received from a merchant of the product. The request can identify at least the merchant, the party, and the product requested for purchase. One or more business rules and auditing parameters for auditing the request can be identified based on the identity of the merchant. The contents of the request can then be audited to determine if the request satisfies the audit parameters. The contents of the request can also be used to identify historical transactions for the party, which can be used to determine if the current request violates one or more of the audit parameters.

Abstract: An adjudicated prescription claim transaction response is received and includes a total amount paid by the claims processor, a patient pay amount, and the pharmacy's Usual and Customary Charge amount for a product/service. The adjudicated response can be evaluated to determine it was approved/paid and the total amount paid by the claims processor is zero or less. An income audit evaluation may be conducted by comparing the patient pay amount to the Usual and Customary Charge amount. Based on the Usual and Customary Charge amount being less than or less than or equal to the patient pay amount, a reversal transaction can be generated and transmitted to a claims processor computer for adjudication. Further, the adjudicated prescription claim transaction response can be converted from an approved/paid response to (or replaced by) a rejected adjudicated prescription claim transaction response and transmitted to the pharmacy computer that initiated the prescription claim transaction.

Abstract: An adjudicated response to a healthcare transaction for a product or service for a patient is received and includes a transaction submission time, and transaction comparison data. The transaction comparison data can be compared to a multitude of transaction records of previously processed healthcare transactions to identify a match. The transaction submission time for each of the received healthcare transaction and stored healthcare transaction can be received and compared to one another to determine a submission time difference between the submission time for the healthcare transaction and the stored healthcare transaction. The submission time difference can be compared to a time limit threshold to determine if the difference satisfies the time limit threshold. Based on the determination that the submission time difference satisfies the threshold, the received healthcare transaction can be determined to be a request for a service, such as prior authorization assistance.

Abstract: Systems and methods are provided for determining the operational status of third-party switch/service providers. The service provider computer receives healthcare transactions and determines if each transaction is to be processed by a third-party switch provider system, either under a contract between the pharmacy and the third-party switch provider or under an exclusivity arrangement between the transaction payer and the third-party switch provider. Healthcare transactions are sent to the third-party switch provider for processing. If the transmission is not successful, the service provider computer will determine if the third-party switch provider system is operating.

Abstract: Embodiments of the invention may include systems and methods for notifying a prescriber or other entity of duplicate product prescriptions. According to one embodiment, a method for processing prescriptions is provided that may include the operations of: receiving a healthcare transaction that identifies a current prescribed product, a patient, and a current prescriber who prescribed the current prescribed product; retrieving patient history for the patient; determining the following based on the patient history: that the patient has previously received a previous equivalent product equivalent to the current prescribed product identified in the healthcare transaction and an identity of a previous prescriber of the previous equivalent product; and transmitting a notification to at least one of the previous prescriber or the current prescriber, wherein the notification identifies potential duplicate products.