PHARMACEUTICAL CLAIM NETWORK ROUTING SYSTEM
Systems and methods for routing pharmaceutical claims in a network are provided. The system includes a network interface that includes a receiver and a transmitter. The receiver is configured to receive an electronic prescription and patient information over a communications network and the transmitter configured to prepare data for transmission over the communications network. The system includes at least one processor communicatively coupled to the network interface. The processor is configured for receiving, using the at least one processor and via the communications network, the electronic prescription. The processor is further configured for accessing a database of pricing data communicatively coupled to the communications network. The processor is configured to select a suggested pharmacy accessible to the patient by evaluating the plurality of participating pharmacies. The processor is configured to send the prescription electronically to a computing system of the suggested pharmacy for fulfillment.
1 . A system for routing electronic prescriptions, the system comprising:
a network interface that includes a receiver and a transmitter, the receiver configured to receive an electronic prescription and patient information over a communications network and the transmitter configured to prepare data for transmission over the communications network;
at least one processor communicatively coupled to the network interface, the at least one processor configured for:
receiving, using the at least one processor and via the communications network, the electronic prescription comprising a prescribed healthcare good associated with a claim for adjudication by a prescription benefits manager (PBM);
receiving, using the at least one processor and via the communications network, the patient information electronically from a patient-specific data store communicatively coupled to the communications network, the patient information comprising an identifier linking a patient to a prescription benefit plan and a fulfilling computing system associated with a fulfilling pharmacy, the patient-specific data store configured to store data pertaining to a patient-specific profile;
accessing, using the at least one processor and via the communications network, a database of pricing data communicatively coupled to the communications network, the database of pricing data stored remotely and accessible via the communications network, the database of pricing data comprising prices of goods at a plurality of participating pharmacies;
selecting, using the at least one processor, a suggested pharmacy accessible to the patient by evaluating the plurality of participating pharmacies at least in part on proximity to the patient and the prices of goods;
sending, using the at least one processor and via the communications network, the prescription electronically to a computing system of the suggested pharmacy for fulfillment;
determining, using the at least one processor, whether a patient question received from the patient via a user interface is to be directed to at least one of the suggested pharmacy, a professional health services representative, or an insurance benefits manager;
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the insurance benefits manager via the communications network, the patient question electronically to the computing system of the insurance benefits manager;
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the professional health services representative via the communications network, the patient question electronically to the computing system of the professional health services representative; and
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the suggested pharmacy via the network interface, the patient question electronically to the computing system of the suggested pharmacy.
2 . The system of claim 1 , wherein the computing system of the suggested pharmacy is automatically chosen to be a pharmacy associated with the patient.
3 . The system of claim 1 , wherein identifying the suggested pharmacy comprises:
identifying, via the communications network, a plurality of computing systems associated with suggested pharmacy, the plurality of computing systems communicatively coupled to the communications network,
providing, via the communications network, a list of the computing systems associated with the suggested pharmacy to a user in a selectable format, and
receiving, via the communications network, an input from the user indicating a selected computing system of a selected pharmacy, the selected computing system of the selected pharmacy communicatively coupled to the communications network.
4 . The system of claim 1 , wherein the plurality of participating pharmacies participate in a bidding process that includes a first off-cycle bid and a second off-cycle bid.
5 . The system of claim 4 , wherein the first off-cycle bid and the second off-cycle bid are valid for a second period of time that is shorter than a first period of time associated with a regular pricing cycle.
6 . The system of claim 1 , wherein the identifier is a patient-specific identification code or username linking the patient to the patient-specific profile, which stores patient-specific information, including at least one of the prescription benefit plan, a birthdate, a name, and an address.
7 . The system of claim 1 , wherein the patient-specific profile also stores financial account information for the patient, and wherein the at least one processor further comprises deducting payment from the financial account information when the electronic prescription is received, adjudicated, or fulfilled by a selected computing system of a selected pharmacy.
8 . The system of claim 1 , further comprising:
generating, using the at least one processor, a claim switch for authorization, in response to determining that the suggested pharmacy is not the fulfilling computing system associated with the fulfilling pharmacy.
9 . A non-transitory machine-readable medium storing instructions that, when executed by at least one processor, cause the at least one processor to perform operations comprising:
receiving, via a communications network communicatively coupled to a network interface, an electronic prescription comprising a prescribed healthcare good associated with a claim for adjudication by a prescription benefits manager (PBM), the network interface including a receiver and a transmitter, the receiver configured to receive the electronic prescription and patient information over the communications network and the transmitter configured to prepare data for transmission over the communications network;
receiving, via the communications network, the patient information electronically from a patient-specific data store communicatively coupled to the communications network, the patient information comprising an identifier linking a patient to a prescription benefit plan and a fulfilling computing system associated with a fulfilling pharmacy, the patient-specific data store configured to store data pertaining to a patient-specific profile;
accessing, via the communications network, a database of pricing data communicatively coupled to the communications network, the database of pricing data stored remotely and accessible via the communications network, the database of pricing data comprising prices of goods at a plurality of participating pharmacies;
selecting a suggested pharmacy accessible to the patient by evaluating the plurality of participating pharmacies at least in part on proximity to the patient and the prices of goods;
sending, via the communications network, the prescription electronically to a computing system of the suggested pharmacy for fulfillment;
determining whether a patient question received from the patient via a user interface is to be directed to at least one of the suggested pharmacy, a professional health services representative, or an insurance benefits manager;
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the insurance benefits manager via the communications network, the patient question electronically to the computing system of the insurance benefits manager;
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the professional health services representative via the communications network, the patient question electronically to the computing system of the professional health services representative; and
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the suggested pharmacy via the network interface, the patient question electronically to the computing system of the suggested pharmacy.
10 . The non-transitory machine-readable medium of claim 9 , wherein the computing system of the suggested pharmacy is automatically chosen to be a pharmacy associated with the patient.
11 . The non-transitory machine-readable medium of claim 9 , wherein identifying the suggested pharmacy comprises:
identifying, via the communications network, a plurality of computing systems associated with suggested pharmacy, the plurality of computing systems communicatively coupled to the communications network,
providing, via the communications network, a list of the computing systems associated with the suggested pharmacy to a user in a selectable format, and
receiving, via the communications network, an input from the user indicating a selected computing system of a selected pharmacy, the selected computing system of the selected pharmacy communicatively coupled to the communications network.
12 . The non-transitory machine-readable medium of claim 9 , wherein the plurality of participating pharmacies participate in a bidding process that includes a first off-cycle bid and a second off-cycle bid.
13 . The non-transitory machine-readable medium of claim 12 , wherein the first off-cycle bid and the second off-cycle bid are valid for a second period of time that is shorter than a first period of time associated with a regular pricing cycle.
14 . The non-transitory machine-readable medium of claim 9 , wherein the identifier is a patient-specific identification code or username linking the patient to the patient-specific profile, which stores patient-specific information, including at least one of the prescription benefit plan, a birthdate, a name, and an address.
15 . The non-transitory machine-readable medium of claim 9 , wherein the patient-specific profile also stores financial account information for the patient.
16 . A computer-implemented method comprising:
receiving, using at least one processor via a communications network communicatively coupled to a network interface, an electronic prescription comprising a prescribed healthcare good associated with a claim for adjudication by a prescription benefits manager (PBM), the network interface including a receiver and a transmitter, the receiver configured to receive the electronic prescription and patient information over the communications network and the transmitter configured to prepare data for transmission over the communications network;
receiving, using the at least one processor and via the communications network, the patient information electronically from a patient-specific data store communicatively coupled to the communications network, the patient information comprising an identifier linking a patient to a prescription benefit plan and a fulfilling computing system associated with a fulfilling pharmacy, the patient-specific data store configured to store data pertaining to a patient-specific profile;
accessing, using the at least one processor and via the communications network, a database of pricing data communicatively coupled to the communications network, the database of pricing data stored remotely and accessible via the communications network, the database of pricing data comprising prices of goods at a plurality of participating pharmacies;
selecting, using the at least one processor, a suggested pharmacy accessible to the patient by evaluating the plurality of participating pharmacies at least in part on proximity to the patient and the prices of goods;
sending, using the at least one processor and via the communications network, the prescription electronically to a computing system of the suggested pharmacy for fulfillment;
determining, using the at least one processor, whether a patient question received from the patient via a user interface is to be directed to at least one of the suggested pharmacy, a professional health services representative, or an insurance benefits manager;
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the insurance benefits manager via the communications network, the patient question electronically to the computing system of the insurance benefits manager;
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the professional health services representative via the communications network, the patient question electronically to the computing system of the professional health services representative; and
routing, using the network interface having the transmitter and in response to determining the patient question received from the patient via the user interface is to be directed to the suggested pharmacy via the network interface, the patient question electronically to the computing system of the suggested pharmacy.
17 . The method of claim 16 , wherein the computing system of the suggested pharmacy is automatically chosen to be a pharmacy associated with the patient.
18 . The method of claim 16 , wherein identifying the suggested pharmacy comprises:
identifying, via the communications network, a plurality of computing systems associated with suggested pharmacy, the plurality of computing systems communicatively coupled to the communications network,
providing, via the communications network, a list of the computing systems associated with the suggested pharmacy to a user in a selectable format, and
receiving, via the communications network, an input from the user indicating a selected computing system of a selected pharmacy, the selected computing system of the selected pharmacy communicatively coupled to the communications network.
19 . The method of claim 16 , wherein the plurality of participating pharmacies participate in a bidding process that includes a first off-cycle bid and a second off-cycle bid.
20 . The method of claim 19 , wherein the first off-cycle bid and the second off-cycle bid are valid for a second period of time that is shorter than a first period of time associated with a regular pricing cycle.