Dynamic claims adjudication

摘要

A dynamic claims adjudication system is provided that implements a dynamic claims adjudication process to provide flexible determination of the adjudication rule set to be used to adjudicate a claim for a particular prescription drug regardless of the mandates of the formulary and the rigidity of the tier into which the drug is placed on the formulary. The claims adjudication system and corresponding methods dynamically determine the adjudication rule set to be used to adjudicate a claim based on an analysis of criteria and identification of a tier changing criteria. Accordingly, the rigidity of conventional formulary based claims adjudication is eliminated in favor of dynamic and flexible real time claims adjudication.

主权项

1. A system for dynamic claim adjudication, the system comprising:
a non-transitory computer readable medium configured to store computer executable programmed modules and information; a processor communicatively coupled with the non-transitory computer readable medium configured to obtain information and execute programmed modules stored therein; a members module stored in the non-transitory computer readable medium and configured to be executed by the processor to store in the medium information about a plurality of members of one or more prescription drug benefits programs; a drugs module stored in the non-transitory computer readable medium and configured to be executed by the processor to store in the medium information about a plurality of drugs; a claims module stored in the non-transitory computer readable medium and configured to be executed by the processor to store in the medium information about a plurality of previously adjudicated claims; a benefits module stored in the non-transitory computer readable medium and configured to be executed by the processor to implement a prescription drug benefits program; and a point of sale module stored in the non-transitory computer readable medium and configured to be executed by the processor to
receive a claim adjudication request for a prescription drug benefits program, wherein the claim adjudication request comprises an identification of a member and an identification of a drug,obtain information relating to the claim adjudication request from one or more of the members module, the drugs module, the claims module, and the benefits module,if the drug is included in a formulary of the prescription drug benefits program,
analyze said information to determine an original tier for the claim adjudication request,determine whether one or more tier changing criteria apply to the claim adjudication request,if it is determined that one or more tier changing criteria apply, determine an end tier based on said one or more tier changing criteria, obtain claim adjudication instructions associated with said end tier, and implement those claim adjudication instructions to adjudicate the claim adjudication request in accordance with said end tier, and,if it is determined that no tier changing criteria apply, obtain claim adjudication instructions associated with said original tier, and implement those claim adjudication instructions to adjudicate the claim adjudication request in accordance with said original tier,if the drug is not included in the formulary of the prescription drug benefits program,
determine whether the drug was previously purchased by the member, within a predetermined time period, based on one or more previously adjudicated claims for the member stored in the medium, and,if it is determined that the drug was previously purchased by the member within the predetermined time period, adjudicate the claim adjudication request by approving the drug even though it is not included in the formulary of the prescription drug benefits program, andprovide results of said adjudication in response to the claim adjudication request.