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 processing a medical insurance eligibility claim request transaction on a cross benefit clearinghouse computer system in real-time and during a single real-time transaction session, the method comprising:
converting, on the cross benefit clearinghouse computer system, the medical insurance eligibility transaction to an pharmacy insurance eligibility request transaction;
submitting, in real-time from the cross benefit clearinghouse computer system, the pharmacy insurance eligibility request transaction to a pharmacy insurance company for a patient;
receiving on the cross benefit clearinghouse computer system a pharmacy insurance eligibility response corresponding to the pharmacy insurance eligibility transaction from the insurance company;
evaluating an eligibility response in the pharmacy insurance eligibility response to determine whether the patient has pharmacy insurance coverage;
converting the pharmacy insurance eligibility response to a medical insurance transaction on the cross benefit clearinghouse computer system if the eligibility response corresponds to the patient having pharmacy insurance coverage; and
returning the medical insurance transaction to the medical claim clearinghouse from the cross benefit clearinghouse computer system to be routed to an initial submitting medical provider computer system.
2 . The method of claim 1 , wherein the pharmacy insurance eligibility transaction is submitted through a pharmacy claims switch for the pharmacy insurance company.
3 . The method of claim 1 , wherein the medical insurance eligibility transaction is received directly from a medical billing system.
4 . The method of claim 1 , wherein the medical insurance eligibility transaction is received from a medical claim clearinghouse, to which a medical billing system that originates the medical insurance eligibility transaction is linked.
5 . The method of claim 1 , wherein:
the medical insurance eligibility request transaction is an Accredited Standards Committee (ASC) X 12 270 eligibility claim request transaction;
the medical insurance eligibility response transaction is an ASC X 12 271 transaction;
the pharmacy insurance eligibility request transaction is a National Council for Prescription Drug Programs (NCPDP) El eligibility request transaction; and
the pharmacy insurance eligibility response is a NCPDP E 1 eligibility response.
6 . A method for a cross benefit clearinghouse computer system to process a medical insurance eligibility request transaction including an identifier for a particular pharmaceutical product in real-time and during a single real-time transaction session, the method comprising:
converting the medical insurance eligibility claim request transaction to a pharmacy benefit predetermination insurance transaction on the cross benefit clearinghouse computer system;
submitting, in real-time from the cross benefit clearinghouse computer system, the pharmacy insurance benefit predetermination transaction to at least one of a computer system of a pharmacy insurance company of a patient and a computer system of a pharmacy benefits manager of the patient through a pharmacy claims switch therefor;
receiving a pharmacy insurance benefit predetermination response from at least one of the pharmacy insurance company of the patient and the pharmacy benefits manager of the patient;
evaluating the pharmacy insurance benefit predetermination response to determine if the patient has pharmacy insurance coverage and the specific coverage for the particular pharmaceutical product corresponding to the submitted identifier;
converting the pharmacy insurance response to a medical insurance eligibility response transaction on the cross benefit clearinghouse computer system; and
returning the medical insurance eligibility response transaction from the cross benefit clearinghouse computer system to a computer system of an initial submitting medical provider.
7 . The method of claim 6 , wherein:
the medical insurance eligibility request transaction is an ASC X 12 270 eligibility request transaction; and
the medical insurance eligibility response transaction is an ASC X 12 271 transaction.
8 . The method of claim 7 , wherein:
the pharmacy insurance benefit predetermination request transaction is an NCPDP B 1 claim request transaction followed by an NCPDP B 2 claim reversal transaction; and
the pharmacy insurance benefit predetermination response is an NCPDP B 1 response followed by an NCPDP B 2 response;
9 . The method of claim 7 , wherein:
the pharmacy insurance transaction is an NCPDP D 1 predetermination of benefits transaction; and
the pharmacy insurance response is an NCPDP D 1 response.
10 . The method of claim 6 , wherein the medical insurance transaction is routed through a medical claim clearinghouse to the initial submitting medical provider.
11 - 24 . (canceled)