SYSTEMS AND METHODS FOR ADJUSTING BENEFIT LEVELS FOR HEALTHCARE TRANSACTIONS PREVIOUSLY REJECTED FOR PRIOR AUTHORIZATION BY A PRIMARY PAYOR

摘要

Systems and methods are provided for adjusting secondary benefit levels for healthcare transactions for which primary benefits were previously rejected for lack of prior authorization by a primary payor. A healthcare transaction may be received from a primary payor computer. The transaction may include patient information, loyalty card information, a request for healthcare benefits, and a refill request for a prescribed medication or service. The administrator computer can determine the transaction is approved by the primary payor computer. The transaction can include a designation of a primary benefit from the primary payor. The administrator computer can determine that a prior authorization requirement for the primary payor has been satisfied based in part on the determination that the transaction is approved by the primary payor. The administrator computer can also change the healthcare benefits provided for the client from a second secondary benefits program to a first secondary benefits program.

主权项

1. A computer-implemented method, comprising:
receiving, at an administrator computer from a primary payor computer associated with a primary payor, a healthcare transaction for a patient, wherein the healthcare transaction comprises patient information, loyalty card information, a request for a provision of healthcare benefits, and a request for a refill of a prescribed medication or service; determining, by the administrator computer, that the healthcare transaction is approved by the primary payor computer, wherein the healthcare transaction includes a designation of a primary benefit from the primary payor; determining, by the administrator computer, that a prior authorization requirement for the primary payor has been satisfied based at least in part on the determination that the healthcare transaction is approved by the primary payor computer; and changing, by the administrator computer, the provision of healthcare benefits for the client from an administrator associated with the administrator computer from a second secondary benefits program to a first secondary benefits program.