Generating Patient Eligibility Data Indicative of Patient Eligibility for Healthcare Services Using Claim Transaction Data

摘要

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.

主权项

1. A system, comprising:
at least one memory storing computer-executable instructions; and at least one processor configured to access the at least one memory and execute the computer-executable instructions to:
receive a first claims processor identifier identifying a claims processor, wherein the first claims processor identifier comprises at least one of a Bank Identification Number (BIN), a Processor Control Number (PCN), or a Group Identifier (ID);receive healthcare service identifying information identifying a healthcare service, wherein the healthcare service comprises medication adherence counseling;receive one or more eligibility parameters including a threshold number of days past due for a refill of a prescription drug or an alternative drug in a therapeutic class that includes the prescription drug;receive, from a first healthcare provider computer, a first healthcare claim transaction;parse the first healthcare claim transaction to determine a second claims processor identifier, first patient identifying information, a first National Drug Code (NDC), a dispensing date, and a days supply included in the first healthcare claim transaction, wherein the first NDC identifies the prescription drug, and wherein the prescription drug is prescribed for treatment of a chronic condition and dispensed, on the dispensing date, to a patient identified by the patient identifying information;determine that the second claims processor identifier matches the first claims processor identifier;determine an expected refill date using the dispensing date and the days supply;determine that the threshold number of days has elapsed since the expected refill date; determine that the patient is eligible for the healthcare service based at least in part on the determination that the threshold number of days has elapsed since the expected refill date;generate an eligibility data record indicating that the patient is eligible for the healthcare service, wherein generating the eligibility data record comprises storing a patient identifier corresponding to the first patient identifying information and the healthcare service identifying information identifying the healthcare service in the eligibility data record;receive, from a second healthcare provider computer, a second healthcare claim transaction;parse the second healthcare transaction to determine second patient identifying information and a second NDC included in the second healthcare claim transaction;determine that the second patient identifying information corresponds to the patient identifier;determine that the second NDC does not match the first NDC;generate an eligibility notification message indicating that the patient is eligible for the healthcare service; andtransmit the eligibility notification message to the second healthcare provider computer.