System and method for web-based claim management
The system includes a variety of aspects which allow users to efficiently receive reimbursement for claims. Claims accepted by CMS result in reimbursement for claimants. Claims rejected by CMS represent lost revenue for claimants. In order to maximize accepted claims and minimize rejected claims, the system provides for the generation of more accurate PDE files for submission and for the accumulation and formatting of information received from CMS to facilitate correction of PDE errors. These aspects work in tandem to minimize lost revenue for the claimant. Further, aspects described herein help minimize PDE error rates. Such minimization of errors can affect the reputation, business model, credibility, and competitive posture of Part D plan sponsors. Accordingly, minimization of PDE error rates is important to the overall design, function, and profitability of any Medicare Part D plan sponsor.
1. A method of generating and updating a formatted Prescription Drug Event file on a server, the method comprising:
providing a computer program with a web-based interface to a service provider computer system, the service provider computer system containing a covered amount and a non-covered amount for a prescription for a patient;
receiving claim information comprising a claim identifier, a patient identifier for the patient, and a prescription drug identifier for the prescription from a user via the web-based interface;
storing the claim identifier, the patient identifier, and the prescription drug identifier in a server memory;
receiving eligibility information comprising an identifier identifying a patient as a Medicare beneficiary from the user via the web-based interface;
storing the eligibility information in the server memory;
determining financial information based at least in part on a portion of the received claim information and a portion of the eligibility information;
generating a Prescription Drug Event (PDE) file for adjudication based at least in part on the portion of the claim information, the portion of the eligibility information, and the financial information;
electronically transmitting the PDE file to a Centers for Medicare and Medicaid Services (CMS) computer;
receiving updated claim or eligibility information from the user via the web-based interface, the updated claim or eligibility information pertaining to the PDE file;
storing the updated claim or eligibility information electronically;
electronically receiving a rejection of the PDE file from the CMS computer;
detecting potential errors by calculating additional fields in the PDE file based upon error trends and root cause analysis for previously tracked errors, the claim information and the eligibility information and the updated claim or eligibility information;
checking the additional fields for financial and format errors;
automatically loading and updating the rejected PDE file to include the updated claim or eligibility information;
automatically submitting the updated rejected PDE file to the CMS computer based at least on the checking the additional fields for financial and format errors;
receiving, subsequent to automatically submitting the updated rejected PDE file to the CMS computer, one of a rejection of the updated rejected PDE file and an acceptance of the updated rejected PDE file from the CMS computer;
consequent to receiving the rejection of the updated rejected PDE file from the CMS computer:
associating an edit code with the claim associated with the PDE file; and
transmitting the edit code and the updated rejected PDE file to the service provider computer system, wherein a report is generated by the program on the service provider computer system comprising the edit code and claim identifier; and
consequent to receiving the acceptance of the updated rejected PDE file from the CMS computer:
transmitting reimbursement and eligibility information to the service provider computer system, wherein the covered amount and non-covered amount for the prescription is updated and the eligibility status for the patient is updated to eligible by the program on the service provider computer system.
2. The method of claim 1 , further comprising transmitting the PDE file to the user via the web-based interface.
3. The method of claim 1 , wherein the claim information is indicative of a plurality of pharmaceutical transactions.
4. The method of claim 1 , further comprising:
validating the determined financial information.
5. A system for generating and updating a formatted Prescription Drug Event file, the system comprising:
a transmitter configured to transmit a computer program with a web-based interface to a service provider computer system, the service provider computer system containing a covered amount and a non-covered amount for a prescription;
a receiver configured to receive claim information and eligibility information from a user via a web-based interface;
a processor configured to determine financial information based at least in part on a portion of the received claim information and a portion of the eligibility information,
wherein the processor is further configured to generate a Prescription Drug Event (PDE) file for adjudication based at least in part on the portion of the claim information, the portion of the eligibility information, and the financial information;
the transmitter further configured to electronically transmit the PDE file to a Centers for Medicare and Medicaid Services (CMS) computer; and
a system memory configured to store the claim information, the eligibility information, and the financial information;
wherein, the receiver is further configured to:
receive updated claim or eligibility information from the user via the web-based interface, the updated claim or eligibility information pertaining to the PDE file, and
electronically receive a rejection of the PDE file from the CMS computer;
wherein the processor is further configured to:
store the updated claim or eligibility information electronically;
detect potential errors by calculating additional fields in the PDE file based upon error trends and root cause analysis for previously tracked errors, the claim information and the eligibility information and the updated claim or eligibility information;
check the additional fields for financial and format errors; and
automatically load and update the rejected PDE file to include the updated claim or eligibility information; and
wherein the transmitter is further configured to automatically submit the updated rejected PDE file to the CMS computer based at least on the check the additional fields for financial and format errors; and
wherein the transmitter, subsequent to receiving a rejection of the updated rejected PDE file from the CMS computer by the receiver, is further configured to:
associate an edit code with the claim associated with the PDE file; and
transmit the updated rejected PDE file and an associated edit code to the service provider computer system, wherein the computer program on the service provider computer system generates a report comprising the edit code and claim identifier.
6. The system of claim 5 , wherein the memory comprises a web-accessible database.
7. The system of claim 5 , wherein the transmitter is further configured to transmit the PDE file to the user via the web-based interface.
8. The system of claim 5 , wherein the processor is further configured to validate the determined financial information.
9. A method of updating medical claims implemented by a claims management system comprising a processor and memory, the method comprising:
providing a computer program with a web-based interface to a service provider computer system, the service provider computer system containing a covered amount and a non-covered amount for a prescription;
storing a plurality of claim files in an electronic database in system memory, each claim file associated with a unique claim number and comprising claim information and eligibility information;
electronically receiving updated claim or eligibility information from a user of the computer program, the updated claim or eligibility information pertaining to one or more of the plurality of claim files in the database;
storing the updated claim or eligibility information in the electronic database in the system memory
electronically receiving rejected claim files from a payor, wherein the rejected claim files correspond to at least a portion of the plurality of claim files stored in the electronic database;
automatically loading the rejected claim files and automatically updating at least a portion of the rejected claim files upon loading to include at least a portion of the updated claim or eligibility information;
detecting potential errors by calculating additional fields in the at least a portion of the plurality of claim files, the calculation based upon error trends and root cause analysis for previously tracked errors, the claim information and the eligibility information and the updated claim or eligibility information;
checking the additional fields for financial and format errors; and
automatically submitting the updated rejected claim files to the payor based at least on the checking the additional fields for financial and format errors;
consequent to the updated rejected claim files subsequently accepted by the payor:
transmitting reimbursement and eligibility information to the service provider computer system;
updating the covered amount and non-covered amount for the prescription by the program on the service provider computer system; and
updating an eligibility status for the patient to eligible.
10. The method of claim 9 , wherein the updated claim or eligibility information is received from the user via a web-based interface.
11. The method of claim 9 , wherein each of the plurality of claim files is a PDE file.
12. The method of claim 9 , wherein the payor is the Centers for Medicare and Medicaid Services (CMS).