Systems and methods for determining and communicating patient incentive information to a prescriber

Patent metadata

Field	Value
Publication number	US-12548079-B2
Application number	US-202318098150-A
Country	US
Kind code	B2
Filing date	Jan 18, 2023
Priority date	Feb 14, 2014
Publication date	Feb 10, 2026
Grant date	Feb 10, 2026

Abstract

Systems and methods are provided for determining and communicating patient incentive information to a prescriber. The patient incentive information may adjust the patient copay amount for a prescribed medication. The patient incentive information may be determined by evaluating pharmacy identification information and medication identifiers in a received prescription benefit check transaction and/or adjudicated response to a healthcare transaction to determine if an incentive is available to be applied to the current transaction. The incentive amount may be retrieved and the patient copay amount in the adjudicated response may be amended prior to transmitting the adjudicated response to the prescriber of the medication.

First claim

That which is claimed is:

1 . A computer-implemented method, comprising:
receiving, from a prescriber computer, a prescription benefit check transaction; in response to, and in real-time or near real-time relative to receiving the prescription benefit check transaction, reformatting, by one or more service provider computers, the prescription benefit check transaction to generate a prescriber billing request transaction, in a National Council for Prescription Drug Programs (NCPDP) format, and associated with a prescription benefit plan and a first claims processor computer, wherein reformatting the prescription benefit check transaction to generate a prescriber billing request transaction in a National Council for Prescription Drug Programs (NCPDP) format, comprises:
populating the prescriber billing request transaction with a medication identifier identifying a medication to be prescribed and a patient identifier identifying a patient to receive the prescribed medication from the prescription benefit check transaction;
populating the prescriber billing request transaction with a pharmacy identifier; and
inserting, by the one or more service provider computers, the pharmacy identifier into the prescriber billing request transaction;
further in response to, and in real-time or near real-time relative to receiving the prescription benefit check transaction, generating an eligibility inquiry transaction in an X12 270 format, different than a format of the prescription benefit check transaction and the NCPDP format, wherein the eligibility inquiry transaction is associated with a health insurance company and a second claims processor computer, wherein generating the eligibility inquiry transaction, in the X12 270 format comprises:
populating the eligibility inquiry transaction with a medication identifier identifying a medication to be prescribed and a patient identifier identifying a patient to receive the prescribed medication from the prescription benefit check transaction; and
populating the eligibility inquiry transaction with a pharmacy identifier; and
transmitting the prescriber billing request transaction to the first claims processor computer; transmitting the eligibility inquiry transaction to the second claims processor computer; receiving adjudicated responses from the first claims processor computer and the second claims processor computer; in response to receiving the adjudicated responses, determining, by the one or more service provider computers, an incentive amount to apply to a first patient copay amount determined from the adjudicated responses; generating, by the one or more service provider computers, a second patient copay amount by reducing the first patient copay amount based upon the incentive amount; generating a prescription benefit check response, in a format different than the prescription benefit check transaction, wherein the prescription benefit check response comprises a transaction type, a transaction status indicator, the second patient copay amount, and a claims processor computer message; and transmitting, by the one or more service provider computers, the prescription benefit check response to the prescriber computer in real-time or near real-time relative to receiving the prescription benefit check transaction.

2 . The computer-implemented method of claim 1 , further comprising:
transmitting, by the one or more service provider computers to the prescriber computer, an incentive notification message indicating the incentive amount and a provider of the incentive amount.

3 . The computer-implemented method of claim 1 , wherein the prescription benefit check response is transmitted in real-time or near real-time to the prescription benefit check response to a prescriber computer responsive to receiving the prescription benefit check transaction.

4 . An apparatus comprising at least one processor and at least one memory including computer program code, the at least one memory and the computer program code configured to, with the processor, cause the apparatus to at least:
receive, from a prescriber computer, a prescription benefit check transaction; in response to, and in real-time or near real-time relative to receiving the prescription benefit check transaction, reformat, by one or more service provider computers, the prescription benefit check transaction to generate a prescriber billing request transaction, in a National Council for Prescription Drug Programs (NCPDP) format, and associated with a prescription benefit plan and a first claims processor computer wherein reformatting the prescription benefit check transaction to generate a prescriber billing request transaction in a National Council for Prescription Drug Programs (NCPDP) format, comprises:
populating the prescriber billing request transaction with a medication identifier identifying a medication to be prescribed and a patient identifier identifying a patient to receive the prescribed medication from the prescription benefit check transaction;
populating the prescriber billing request transaction with a pharmacy identifier; and
inserting, by the one or more service provider computers, the pharmacy identifier into the prescriber billing request transaction;
further in response to, and in real-time or near real-time relative to receiving the prescription benefit check transaction, generate an eligibility inquiry transaction in an X12 270 format, different than a format of the prescription benefit check transaction and the NCPDP format, wherein the eligibility inquiry transaction is associated with a health insurance company and a second claims processor computer, wherein generating the eligibility inquiry transaction, in the X12 270 format comprises:
populating the eligibility inquiry transaction with a medication identifier identifying a medication to be prescribed and a patient identifier identifying a patient to receive the prescribed medication from the prescription benefit check transaction;
populating the eligibility inquiry transaction with a pharmacy identifier; and
transmitting the prescriber billing request transaction to the first claims processor computer;
transmit the eligibility inquiry transaction to the second claims processor computer; receive adjudicated responses from the first claims processor computer and the second claims processor computer; in response to receiving the adjudicated response, determine, by the one or more service provider computers, an incentive amount to apply to a first patient copay amount determined from the adjudicated responses; generate, by the one or more service provider computers, a second patient copay amount by reducing the first patient copay amount based upon the incentive amount; generate a prescription benefit check response, in a format different than the prescription benefit check transaction, wherein the prescription benefit check response comprises a transaction type, a transaction status indicator, the second patient copay amount, and a claims processor computer message; and transmit, by the one or more service provider computers, the prescription benefit check response to the prescriber computer in real-time or near real-time relative to receiving the prescription benefit check transaction.

5 . The apparatus of claim 4 , wherein the at least one memory and the computer program code are further configured to cause the apparatus to at least:
transmit, by the one or more service provider computers to the prescriber computer, an incentive notification message indicating the incentive amount and a provider of the incentive amount.

6 . The apparatus of claim 4 , wherein the prescription benefit check response is transmitted in real-time or near real-time to the prescription benefit check response to a

Assignees

• Mckesson Corp

Inventors

• Pinsonneault Roger G

Classifications

• G06Q10/10

  Office automation; Time management · CPC title

• G16H20/10

  relating to drugs or medications, e.g. for ensuring correct administration to patients · CPC title

• G16H40/20

  for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms · CPC title

• G16H10/60

  for patient-specific data, e.g. for electronic patient records · CPC title

• G06Q40/08 Primary

  Insurance · CPC title