Systems and methods for the identification of available payers for healthcare transactions

1. A method, comprising:

receiving, by a service provider system comprising one or more computers, a reply to a healthcare claim transaction from a claims processor computer;

determining, by the service provider system based at least in part on an evaluation of the reply, that the healthcare claim transaction has been rejected for an eligibility reason indicating either that a patient associated with the healthcare claim transaction is not covered for benefits or that incorrect coverage information was included in the healthcare claim transaction;

generating an eligibility request for the patient;

communicating the eligibility request to an eligibility system;

identifying, by the service provider system based at least in part on the determination that the healthcare claim transaction was rejected for an eligibility reason and a response to the eligibility request, an available payer for the patient; and

communicating, by the service provider system, information associated with the identified available payer to a healthcare provider associated with the healthcare claim transaction.

2. The method of claim 1 , wherein communicating information associated with the identified payer comprises:

appending the information to the reply; and

communicating the reply to a healthcare provider computer associated with the healthcare provider.

3. The method of claim 1 , wherein determining that the healthcare claim transaction has been rejected for an eligibility reason comprises:

identifying a reject code included in the received reply;

comparing the identified reject code to one or more stored reject codes associated with eligibility rejections; and

determining, based upon the comparison, that the healthcare claim transaction has been rejected for an eligibility reason.

4. The method of claim 3 , wherein comparing the identified reject code to one or more stored reject codes comprises comparing the identified reject code to at least one of (i) a reject code for a missing or incomplete Banking Identification Number (BIN), (ii) a reject code for a missing or incomplete group number, (iii) a reject code for a missing or incomplete cardholder identifier, (iv) a reject code indicating that the healthcare claim transaction should be submitted to another processor, (v) a reject code for an unmatched group number, (vi) a reject code for an unmatched cardholder identifier, (vii) a reject code indicating that the patient is not covered, or (viii) a reject code indicating that the patient's coverage has expired.

5. The method of claim 1 , wherein the healthcare claim transaction comprises a first healthcare claim transaction, and further comprising:

generating, by the service provider system a second healthcare claim transaction on behalf of the patient; and

communicating, by the service provider system, the second healthcare claim transaction to a claims processing system associated with the identified available payer.

6. The method of claim 5 , wherein the claims processor computer comprises a first claims processor computer associated with a first payer, and wherein communicating the second healthcare claim transaction to a claims processing system associated with the identified available payer comprises communicating the second healthcare claim transaction to one of (i) the first claims processor computer or (ii) a second claims processor computer associated with a second payer.

7. The method of claim 5 , wherein the reply comprises a first reply, and further comprising:

receiving, by the service provider system from the claims processing system in response to the second healthcare claim transaction, a second reply; and

communicating, by the service provider system, the received second reply to a healthcare provider computer associated with the healthcare provider.

8. The method of claim 5 , further comprising:

communicating, by the service provider system, a message to the healthcare provider indicating that the first healthcare claim transaction is being resubmitted.

9. A system, comprising:

at least one memory operable to store computer-executable instructions; and

at least one processor configured to access the at least one memory and execute the computer-executable instructions to:

receive a reply to a healthcare claim transaction from a claims processor computer;

determine, based at least in part on an evaluation of the reply, that the healthcare claim transaction has been rejected for an eligibility reason indicating either that a patient associated with the healthcare claim transaction is not covered for benefits or that incorrect coverage information was included in the healthcare claim transaction;

generate an eligibility request for the patient;

direct the communication of the eligibility request to an eligibility system;

identify, based at least in part on the determination that the healthcare claim transaction was rejected for an eligibility reason and a response to the eligibility request, an available payer for the patient; and

direct the communication of information associated with the identified available payer to a healthcare provider associated with the healthcare claim transaction.

10. The system of claim 9 , wherein the at least one processor is configured to direct the communication of information associated with the identified available payer by executing the computer-executable instructions to:

append the information to the reply; and

direct the communication of the reply to a healthcare provider computer associated with the healthcare provider.

11. The system of claim 9 , wherein the at least one processor is configured to determine that the healthcare claim transaction has been rejected for an eligibility reason by executing the computer-executable instructions to:

identify a reject code included in the received reply;

compare the identified reject code to one or more stored reject codes associated with eligibility rejections; and

determine, based upon the comparison, that the healthcare claim transaction has been rejected for an eligibility reason.

12. The system of claim 11 , wherein the one or more stored reject codes comprise at least one of (i) a reject code for a missing or incomplete Banking Identification Number (BIN), (ii) a reject code for a missing or incomplete group number, (iii) a reject code for a missing or incomplete cardholder identifier, (iv) a reject code indicating that the healthcare claim transaction should be submitted to another processor, (v) a reject code for an unmatched group number, (vi) a reject code for an unmatched cardholder identifier, (vii) a reject code indicating that the patient is not covered, or (viii) a reject code indicating that the patient's coverage has expired.

13. The system of claim 9 , wherein the healthcare claim transaction comprises a first healthcare claim transaction, and wherein the at least one processor is further configured to execute the computer-executable instructions to:

generate a second healthcare claim transaction on behalf of the patient; and

direct communication of the second healthcare claim transaction to a claims processing system associated with the identified available payer.

14. The system of claim 13 , wherein the claims processor computer comprises a first claims processor computer associated with a first payer, and wherein the claims processing system associated with the identified available payer comprises one of (i) the first claims processor computer or (ii) a second claims processor computer associated with a second payer.

15. The system of claim 13 , wherein the reply comprises a first reply, and wherein the at least one processor is further configured to execute the computer-executable instructions to:

receive, from the claims processing system in response to the second healthcare claim transaction, a second reply; and

direct the communication of the received second reply to a healthcare provider computer associated with the healthcare provider.

16. The system of claim 13 , wherein the at least one processor is further configured to execute the computer-executable instructions to:

direct the communication of a message to the healthcare provider indicating that the first healthcare claim transaction is being resubmitted.

17. A method, comprising:

receiving, by a service provider system comprising one or more computers, a reply to a healthcare claim transaction from a claims processor computer;

generating, by the service provider system based at least in part upon a determination that the healthcare claim transaction has been rejected for an eligibility reason, an eligibility request for a patient associated with the healthcare claim transaction;

communicating, by the service provider system, the eligibility request to an eligibility system;

identifying, by the service provider system based at least in part upon a response to the eligibility request received from the eligibility system, an available payer for the patient; and

communicating, by the service provider system, information associated with the identified available payer to a healthcare provider associated with the healthcare claim transaction.

18. The method of claim 17 , wherein generating an eligibility request based upon a determination that the healthcare claim transaction has been rejected comprises:

identifying a reject code included in the received reply;

comparing the identified reject code to one or more stored reject codes associated with eligibility rejections;

determining, based upon the comparison, that the healthcare claim transaction has been rejected for an eligibility reason; and

generating the eligibility request based upon the determination that the healthcare claim transaction has been rejected for an eligibility reason.