System and method for medical billing systems to submit transactions for services covered under pharmacy benefits
A system and method for medical offices and other non-pharmacy providers using management systems or other billing systems based on the ASC X12 transaction standards to perform eligibility transactions, perform benefit predetermination transactions and to submit claims to pharmacy insurance companies or their pharmacy benefit managers that must receive the transactions as real-time transactions based on the NCPDP transaction standards are disclosed. Same medical offices and non-pharmacy providers can receive electronic remittance advice files from pharmacy insurance companies or their pharmacy benefit managers that contain data formatted and using identifiers that relate to the initial ASC X12 claims submitted.
1. A method for a cross benefit clearinghouse computer system to process batches of medical insurance claims from a medical claims clearinghouse system received over one or more sessions and during the batch processing, the method comprising:
validating that the batch file complies with requirements of a first predetermined standard on the cross benefit clearinghouse computer system;
splitting the batch file into individual medical insurance claims, each of the medical insurance claims including one or more service lines;
splitting the medical insurance claims into separate transactions for each of the one or more service lines thereof on the cross benefit clearinghouse computer system;
storing in a transaction reference data store on the cross benefit clearinghouse computer system, associations between the individual service lines and corresponding ones of the medical insurance claims from which the one or more service lines were split;
converting each of the service lines into a pharmacy insurance claim request in accordance with coding rules for at least one of a pharmacy insurance plan and a pharmacy benefit manager;
assigning either one of a prescription number or a service number to each service line on the cross benefit clearinghouse computer system;
submitting the pharmacy insurance claim requests in real time sessions with a computer system of the respective one of the pharmacy insurance plan and the pharmacy benefit manager separate from the plurality of sessions in which the medical insurance claims were received from the medical claims clearinghouse system;
receiving pharmacy insurance claim responses from the respective one of the computer systems of the pharmacy insurance plan and the pharmacy benefit manager for each of the submitted pharmacy insurance claim requests;
converting, on the cross benefit clearinghouse computer system, the pharmacy insurance claim responses to medical insurance claim acknowledgement transactions based upon the associations in the transaction reference data store;
batching, on the cross benefit clearinghouse computer system, the medical insurance claim acknowledgment transactions for each submission of the pharmacy insurance requests into a file; and
transmitting the file to a computer system of an originator of the medical insurance claims transactions.
2. The method of claim 1 , wherein:
the medical insurance claims transactions are ASC X12 837 claims transactions; and
the first predetermined standard is ASC X12 837.
3. The method of claim 1 , wherein the pharmacy insurance claim request is one of an NCPDP B1 request and a NCPDP S1 request.
4. The method of claim 1 , wherein the pharmacy insurance claim response is one of a NCPDP B1 response and a NCPDP S1 response.
5. The method of claim 1 , wherein the medical insurance acknowledgment transaction is one of a ASC X12 277CA transaction and a ASC X12 835 transaction.
6. A method to process in a real time transaction on a cross benefit clearinghouse computer system a medical insurance claim from a medical claims source and during the real-time processing:
validating, on the cross benefit clearinghouse computer system, that the medical insurance claim complies with requirements of a first predetermined standard;
splitting the medical insurance claim into a separate transaction for each service line thereof on the cross benefit clearinghouse computer system;
storing, in a transaction reference data store, associations between individual service lines and the medical insurance claim from which the service lines were split;
converting on the cross benefit clearinghouse computer system each of the service lines into a pharmacy insurance claim request according to predetermined coding rules;
assigning either one of a prescription number or a service number to each service line on the cross benefit clearinghouse computer system;
submitting each of the pharmacy insurance claim requests in real time sessions with a computer system of a pharmacy insurance processor over respective sessions separate from the plurality of sessions in which the medical insurance claims were received from the medical claim source;
receiving on the cross benefit clearinghouse computer system a pharmacy insurance claim response from the computer system of the pharmacy insurance processor corresponding to the submitted pharmacy insurance claim requests;
converting the pharmacy insurance claim response to medical insurance acknowledgment transactions based upon the associations in the transaction reference data store; and
batching the medical insurance acknowledgement transactions for each submitter into a file on the cross benefit clearinghouse computer system as received over the respective sessions taking place in real time with the computer system of the pharmacy insurance processor;
transmitting the file to a computer system of an originator of the medical insurance claim transactions in a subsequent session separate from the respective sessions with the computer system of the pharmacy insurance processor.
7. The method of claim 6 , wherein:
the medical insurance claim is an ASC X12 837 claim; and
the first predetermined standard is ASC X12.
8. The method of claim 6 , wherein the medical claims source is a medical claims clearinghouse.
9. The method of claim 6 , wherein the medical claims source is a medical billing system.
10. The method of claim 6 , wherein the pharmacy insurance claim request is an NCPDP B1 request.
11. The method of claim 6 , wherein the pharmacy insurance claim request is an NCPDP S1 request.
12. The method of claim 6 , wherein the predetermined coding rules are specific to the pharmacy insurance processor.
13. The method of claim 12 , wherein the pharmacy insurance processor is one of a pharmacy insurance plan and a pharmacy benefits manager.
14. The method of claim 6 , wherein the medical insurance acknowledgment transaction is one of an ASC X12 277CA transaction and a ASC X12 835 transaction.