Apparatus and method for constructing and managing clinical rules

摘要

An apparatus and method are disclosed for defining and managing clinical rules. A computer system provides access to administrators for defining and entering the details of clinical rules for various clients. The administrator selects the prescription products, or medication, for which the clinical rule will apply. The administrator also specifies the coverage criteria to be used for approving coverage of the prescription products. When a prescription claim is submitted to the computer system, the appropriate clinical rule is selected and applied to determine if the cost of the prescription product should be covered.