SYSTEMS AND METHODS FOR DETERMINING AND COMMUNICATING A BENEFIT RESPONSE MESSAGE

摘要

Systems and methods are provided for determining and communicating a benefit response message corresponding to a benefit contract status. The benefit contract status may be based upon a benefit group identifier included in a healthcare transaction. The healthcare transaction may be received by the service provider computer from a healthcare provider computer. The healthcare transaction may include prescription transaction information. The service provider may utilize the prescription transaction information to determine a benefit group identifier. The service provider may determine a contract status of the benefit group associated with the benefit response message. The service provider may transmit a provider or a limited provider message to the healthcare provider computer based upon the determination of the contract status of the benefit group.

主权项

1. A computer-implemented method, comprising:
receiving, by one or more computers associated with a service provider from a healthcare provider computer associated with a healthcare provider, a healthcare transaction comprising prescription transaction information; determining, by the one or more computers associated with the service provider, that the prescription transaction information includes at least one benefit group identifier; routing, by the one or more computers associated with the service provider, the healthcare transaction to a benefit group associated with the benefit group identifier; receiving, by the one or more computers associated with the service provider from the benefit group associated with the benefit group identifier, a benefit response message, the benefit response message including benefit response information comprising at least the benefit group identifier, a patient co-pay amount and one or more formulary alternatives; determining, by the one or more computers associated with the service provider and based at least in part on the benefit group identifier, a contract status of the benefit group associated with the benefit response message, wherein; if the determination is a contracted entity status, transmitting, by the one or more computers associated with the service provider, a provider message to the healthcare provider computer associated with the healthcare provider, the provider message including a first benefit information portion and a second benefit information portion accessible for display by the healthcare provider computer; and if the determination is a non-contracted entity status, transmitting, by the one or more computers associated with the service provider, a limited provider message to the healthcare provider computer associated with the healthcare provider, the limited provider message including the first benefit information portion and the second benefit information portion, wherein only the first benefit information is accessible for display by the healthcare provider computer.