System for pre-adjudicating and modifying data packets in health claim processing system
AssigneeFlipt, Inc
InventorsAaron Greenblatt, Lev Peysekhman
Life of this patent
Estimating the term…
Abstract
In accordance with some embodiments, an alternative system for processing a data packet received via a secure pharmacy prescription claim network is provided, in which data included in the data packet as received from a pharmacy system is modified prior to being routed to a PBM. The data packet may be modified such that a first BIN/PCN is replaced by a second BIN/PCN and a Consumer Price is added. The alternative system allows for a third party to act as a switchboard for prescription claims such that requests for prescription claims received from pharmacy systems are pre-adjudicated and data packets included in the requests are modified prior to being routed to a PBM selected by the third party.
Claims20
A system for routing pharmacy prescription fulfillment requests, the system comprising:
- a processor;
- a non-transitory memory storing a program, the processor operable with the program to:
- (a) receive, by the processor, a first data, the first data comprising (i) a request for fulfillment of a prescription at a pharmacy corresponding to a pharmacy device transmitting the first data;
- (ii) a first BIN/PCN identifier that had caused the pharmacy to transmit the first data to the system, and (iii) a unique identifier associated with the request;
- (b) select one of the following options:
- (i) fulfilling the prescription based on a first pricing contract previously established with the pharmacy;
- and (ii) utilizing at least one second pricing contract of at least one of a plurality of third party pharmacy benefit managers for fulfillment of the prescription;
- (c) only if option (ii) in (b) is selected, perform (d)— (f), otherwise utilize the first pricing contract for fulfillment of the prescription without transmitting the first data to any of the plurality of third party pharmacy benefit managers for fulfillment of the prescription;
- (d) identify one of the plurality of third party pharmacy benefit managers, for the fulfillment of the prescription;
- (e) modify the first data by replacing the first BIN/PCN identifier with a second BIN/PCN identifier that corresponds to the one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription, thereby generating a modified first data;
- and
- (f) transmit, via a prescription processing computer network, the modified first data to a device of the one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription.
The system of claim 2, wherein the request is received from the pharmacy device via a prescription processing computer network dedicated to processing requests for fulfillment of pharmaceutical prescriptions.
A non-transitory computer-readable medium storing instructions for directing a processor to perform a process, the process comprising:
- (a) receiving, by the processor, a first data, the first data comprising (i) a request for fulfillment of a prescription at a pharmacy corresponding to a pharmacy device transmitting the first data;
- (ii) a first BIN/PCN identifier that had caused the pharmacy to transmit the first data to the system, and (iii) a unique identifier associated with the request;
- (b) selecting one of the following options:
- (i) fulfilling the prescription based on a first pricing contract previously established with the pharmacy;
- and (ii) utilizing at least one second pricing contract of at least one of a plurality of third party pharmacy benefit managers for fulfillment of the prescription;
- (c) only if option (ii) in (b) is selected, performing (d)-(f), otherwise utilizing the first pricing contract for fulfillment of the prescription without transmitting the first data to any of the plurality of third party pharmacy benefit managers for fulfillment of the prescription;
- (d) identifying one of the plurality of third party pharmacy benefit managers, for the fulfillment of the prescription;
- (e) modifying the first data by replacing the first BIN/PCN identifier with a second BIN/PCN identifier that corresponds to the one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription, thereby generating a modified first data;
- and
- (f) transmitting, via a prescription processing computer network, the modified first data to a device of the one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription.
Dependencies are inferred from the claim text.