System for pre-adjudicating and modifying data packets in health claim processing system
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.
1 . 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, at a device of an alternative pharmacy benefit manager (APBM) and from a pharmacy device via a prescription processing computer network dedicated to processing requests for fulfillment of pharmaceutical prescriptions, a first data, the first data comprising (i) a request for fulfillment of a prescription at a pharmacy corresponding to the pharmacy device; (ii) a first BIN/PCN identifier that had caused the pharmacy to transmit the first data to the system, and (iii) a user identifier identifying a user associated with the request;
(b) select, based on an objective of cost savings to the user and a consumer price as calculated by the APBM, one of the following options: (i) fulfilling the prescription based on a first pricing contract previously established between the APBM and 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 of the APBM 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 the 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.
2 . The system of claim 1 , wherein the processor is further operable with the program to:
adjudicate the request for the fulfillment of the prescription in order to verify that the prescription is authorized to be redeemed by the user at the pharmacy; and
further modify the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication that the prescription is authorized to be redeemed by the user at the pharmacy.
3 . The system of claim 2 , wherein the processor being operable with the program to adjudicate the request comprises the processor being operable with the program to:
retrieve information corresponding to a pharmacy benefit plan of which the user is a member; and
verify that the fulfillment of the prescription by the user at the pharmacy is within at least one rule of the pharmacy benefit plan.
4 . The system of claim 1 , wherein the processor is further operable with the program to:
determine an out of pocket cost to be paid by the user for the fulfillment of the prescription at the pharmacy; and
further modify the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication of the out of pocket cost.
5 . The system of claim 4 , wherein the processor is further operable with the program to:
charge the out of pocket cost to a financial account associated with the user.
6 . The system of claim 1 , wherein the processor is further operable with the program to:
determine a reward to be provided to the user for the fulfillment of the prescription at the pharmacy; and
cause the reward to be provided to the user.
7 . The system of claim 6 , wherein the processor is further operable with the program to:
determine that the reward to be provided to the user comprises a payment to be made to the user by the pharmacy; and
wherein modifying the first data comprises adding to the first data an indication of the payment to be provided to the user by the pharmacy upon a fulfillment of the prescription.
8 . The system of claim 1 , wherein the processor being operable with the program to select one of a plurality of third party pharmacy benefit managers comprises:
retrieving, from a database, the one of the plurality of third party pharmacy benefit managers identified for the fulfillment of the prescription by the user prior to receiving the first data.
9 . The system of claim 1 , wherein the processor being operable with the program to select the one of the plurality of third party pharmacy benefit managers comprises:
identifying, after receiving the first data, a set of available prices for the prescription, each price of the set of prices corresponding to a different one of the plurality of third party pharmacy benefit managers; and
selecting the different one of the plurality of third party pharmacy benefit managers that corresponds to a price satisfying at least one criteria.
10 . A non-transitory computer-readable medium storing instructions for directing a processor to perform a process, the process comprising:
(a) receiving, at a device of an alternative pharmacy benefit manager (APBM) and from a pharmacy device via a prescription processing computer network dedicated to processing requests for fulfillment of pharmaceutical prescriptions, a first data, the first data comprising (i) a request for fulfillment of a prescription at a pharmacy corresponding to the pharmacy device; (ii) a first BIN/PCN identifier that had caused the pharmacy to transmit the first data to the system, and (iii) a user identifier identifying a user associated with the request;
(b) selecting, based on an objective of cost savings to the user and a consumer price as calculated by the APBM, one of the following options: (i) fulfilling the prescription based on a first pricing contract previously established between the APBM and 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 utilize the first pricing contract of the APBM 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 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 the 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.
11 . The non-transitory computer-readable medium of claim 10 , wherein the process further comprises:
adjudicating the request for the fulfillment of the prescription in order to verify that the prescription is authorized to be redeemed by the user at the pharmacy; and
further modifying the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication that the prescription is authorized to be redeemed by the user at the pharmacy.
12 . The non-transitory computer-readable medium of claim 11 , wherein the process further comprises:
retrieving information corresponding to a pharmacy benefit plan of which the user is a member; and
verifying that the fulfillment of the prescription by the user at the pharmacy is within at least one rule of the pharmacy benefit plan.
13 . The non-transitory computer-readable medium of claim 10 , wherein the process further comprises:
determining an out of pocket cost to be paid by the user for the fulfillment of the prescription at the pharmacy; and
further modifying the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication of the out of pocket cost.
14 . The non-transitory computer-readable medium of claim 10 , wherein the process further comprises:
determining a reward to be provided to the user for the fulfillment of the prescription at the pharmacy; and
causing the reward to be provided to the user.
15 . The non-transitory computer-readable medium of claim 14 , wherein the process further comprises:
determining that the reward to be provided to the user comprises a payment to be made to the user by the pharmacy; and
wherein modifying the first data comprises adding to the first data an indication of the payment to be provided to the user by the pharmacy upon a fulfillment of the prescription.
16 . The non-transitory computer-readable medium of claim 15 , wherein the process further comprises:
retrieving, from a database, the one of the plurality of third party pharmacy benefit managers identified for the fulfillment of the prescription by the user prior to receiving the first data.
17 . The non-transitory computer-readable medium of claim 10 , wherein the process further comprises:
charging the out of pocket cost to a financial account associated with the user.