Systems and Methods for Determining Coverage for Medication or Services Related to Specific Conditions or Levels of Care

摘要

Systems and methods are provided to determine if a prescription is for patient specific condition or level of care requiring a coverage determination such as hospice care or ESRD for a patient as part of healthcare transaction processing. A service provider computer can receive a healthcare transaction from a healthcare provider that includes a medication identifier and a patient identifier. The service provider computer can determine, based on the medication identifier and/or the patient identifier if the healthcare transaction is for a medication related to a specific condition or level of care. The service provider computer can also generate a rejection response to the healthcare transaction based at least in part on the positive determination that the healthcare transaction is for a medication related to the specific condition or level of care, and can transmit the rejection response to the healthcare provider computer for further action if necessary.

主权项

1. A computer-implemented method, comprising:
receiving, by one or more service provider computers associated with a service provider and comprising one or more processors from a healthcare provider computer associated with a healthcare provider, a healthcare transaction comprising healthcare transaction data, wherein the healthcare transaction data comprises a medication identifier identifying a medication to be prescribed and at least one patient identifier identifying a patient to receive the prescribed medication; identifying, by the one or more service provider computers, the healthcare transaction data in the healthcare transaction; determining, by the one or more service provider computers and based on the identified healthcare transaction data, if the healthcare transaction is for a medication for at least one of the end stage renal disease (ESRD) care for the patient or hospice care for the patient; generating, by the one or more service provider computers and based at least in part on the positive determination that the healthcare transaction is for a medication for at least one of the ESRD care for the patient or hospice care for the patient, a rejection response to the healthcare transaction; and transmitting, by the one or more service provider computers, the rejection response to the healthcare transaction to the healthcare provider computer.