Abstract: Systems and methods are provided for determining and communicating patient incentive information to a prescriber. The patient incentive information may adjust the patient copay amount for a prescribed medication. The patient incentive information may be determined by evaluating pharmacy identification information and medication identifiers in a received prescription benefit check transaction and/or adjudicated response to a healthcare transaction to determine if an incentive is available to be applied to the current transaction. The incentive amount may be retrieved and the patient copay amount in the adjudicated response may be amended prior to transmitting the adjudicated response to the prescriber of the medication.

Abstract: Systems and methods are provided for determining and communicating patient incentive information to a prescriber. The patient incentive information may adjust the patient copay amount for a prescribed medication. The patient incentive information may be determined by evaluating pharmacy identification information and medication identifiers in a received prescription benefit check transaction and/or adjudicated response to a healthcare transaction to determine if an incentive is available to be applied to the current transaction. The incentive amount may be retrieved and the patient copay amount in the adjudicated response may be amended prior to transmitting the adjudicated response to the prescriber of the medication.

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: Systems and methods are provided for determining and communicating prescription benefit coverage information to a prescriber of the product, service, or medication. A prescription benefit check request may be received by the service provider computer from a healthcare provider computer for the prescriber of the product, service, or medication. The service provider computer may format a prescription request for the prescribed product, service, or medication and transmit the prescription request to a pharmacy claims processor computer for processing. The service provider computer may receive a prescription response that includes a determination of the prescription request from the pharmacy claims processor computer.

Abstract: Systems and methods are provided for determining patient financial responsibility for multiple prescription products across multiple healthcare transactions. A service provider computer can receive multiple healthcare transactions, and can evaluate each to determine if it includes a total group transaction number and a transaction number. The service provider computer can compare the transaction number to the total group transaction number to determine if all transactions within a group have been received. Once received, the transactions can be transmitted to the claims processor computer for adjudication. Upon receiving the adjudicated response for each transaction within the group, the service provider computer can identify the patient co-pay for each of the adjudicated responses in the group and can calculate a total patient pay amount based on the group of patient co-pays. The total patient pay amount may then be transmitted to a healthcare provider computer associated with a healthcare provider.

Abstract: An improved prescription prior authorization system is disclosed and described herein. The improved prescription prior authorization system provides an improved system and apparatus for prescription prescribers and other healthcare providers to satisfy prior authorization requirements as part of the prescription process. The improved prescription prior authorization system provides mechanisms to a prescriber of medication to more quickly and efficiently satisfy prior authorization requirements for a prescriber and to more quickly provide the prescription to the patient to improve the patient's overall health. The patient's overall health is improved because of the improved likelihood that the patient will receive the product that the prescriber wants to prescribe to the patient. The improved prescription prior authorization system also reduces prescription network traffic and improves the efficiency of the prescription network.

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 and methods are provided for determining patient adherence to a medication protocol by evaluating healthcare transactions. An e-prescription transaction can be received from a prescriber and evaluated to determine if the patient is to receive adherence analysis. If so, the e-prescription data can be stored and the e-prescription can be forwarded to a pharmacy. A healthcare claim transaction for a medication can be received from the pharmacy and forwarded on for adjudication. If approved, the claim transaction data can be evaluated to determine if it matches any stored e-prescription data records. Upon identifying a match, a prescription fill status notification can be generated and transmitted to the prescriber computer associated with the prescriber of the medication in the e-prescription. If the healthcare claim transaction is for a refill or a maintenance medication, a patient adherence level can be calculated and included in the prescription fill status notification.

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: Systems and methods are provided for determining and communicating patient incentive information to a prescriber. The patient incentive information may adjust the patient copay amount for a prescribed medication. The patient incentive information may be determined by evaluating pharmacy identification information and medication identifiers in a received prescription benefit check transaction and/or adjudicated response to a healthcare transaction to determine if an incentive is available to be applied to the current transaction. The incentive amount may be retrieved and the patient copay amount in the adjudicated response may be amended prior to transmitting the adjudicated response to the prescriber of the medication.

Abstract: Systems and methods are provided for determining and communicating prescription benefit coverage information to a prescriber of the product, service, or medication. A prescription benefit check request may be received by the service provider computer from a healthcare provider computer for the prescriber of the product, service, or medication. The service provider computer may format a prescription request for the prescribed product, service, or medication and transmit the prescription request to a pharmacy claims processor computer for processing. The service provider computer may receive a prescription response that includes a determination of the prescription request from the pharmacy claims processor computer.

Abstract: Systems and methods are provided for determining and communicating patient incentive information to a prescriber. The patient incentive information may adjust the patient copay amount for a prescribed medication. The patient incentive information may be determined by evaluating pharmacy identification information and medication identifiers in a received prescription benefit check transaction and/or adjudicated response to a healthcare transaction to determine if an incentive is available to be applied to the current transaction. The incentive amount may be retrieved and the patient copay amount in the adjudicated response may be amended prior to transmitting the adjudicated response to the prescriber of the medication.

Abstract: Systems and methods are provided for determining and communicating intervention service opportunities, such as medication therapy management services, that may be available for a patient, as part of processing a healthcare claim transaction. A healthcare claim transaction, such as a prescription benefit request transaction, may be received by the service provider computer from a healthcare provider computer. The service provider computer may determine if an intervention service is available for the patient and if an available intervention service notification has been transmitted to the pharmacy computer prior to the service provider computer receiving the healthcare claim transaction. The service provider computer may receive an approved adjudicated response and generate a patient intervention service form corresponding to the available intervention service for the patient.

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 and communicating prescription benefit coverage information to a prescriber of the product, service, or medication. A prescription benefit check request may be received by the service provider computer from a healthcare provider computer for the prescriber of the product, service, or medication. The service provider computer may format a prescription request for the prescribed product, service, or medication and transmit the prescription request to a pharmacy claims processor computer for processing. The service provider computer may receive a prescription response that includes a determination of the prescription request from the pharmacy claims processor computer.

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: Systems and methods are provided for determining patient financial responsibility for multiple prescription products across multiple healthcare transactions. A service provider computer can receive multiple healthcare transactions, and can evaluate each to determine if it includes a total group transaction number and a transaction number. The service provider computer can compare the transaction number to the total group transaction number to determine if all transactions within a group have been received. Once received, the transactions can be transmitted to the claims processor computer for adjudication. Upon receiving the adjudicated response for each transaction within the group, the service provider computer can identify the patient co-pay for each of the adjudicated responses in the group and can calculate a total patient pay amount based on the group of patient co-pays. The total patient pay amount may then be transmitted to a healthcare provider computer associated with a healthcare provider.

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 determining patient adherence to a medication protocol by evaluating healthcare transactions. An e-prescription transaction can be received from a prescriber and evaluated to determine if the patient is to receive adherence analysis. If so, the e-prescription data can be stored and the e-prescription can be forwarded to a pharmacy. A healthcare claim transaction for a medication can be received from the pharmacy and forwarded on for adjudication. If approved, the claim transaction data can be evaluated to determine if it matches any stored e-prescription data records. Upon identifying a match, a prescription fill status notification can be generated and transmitted to the prescriber computer associated with the prescriber of the medication in the e-prescription. If the healthcare claim transaction is for a refill or a maintenance medication, a patient adherence level can be calculated and included in the prescription fill status notification.