System for pre-processing drug benefit claims according to processed drug lists
A method of processing drug claims, by: (a) receiving a claim; (b) sorting the claim for processing by determining which processed drug list the claim belongs with; and then (c) processing the claim according to the particular processed drug list to which the claim belongs. A hierarchy of drug lists are used in a preferred order. If the drug is found on the first drug list, the system then moves directly to the processing stage. However, if the drug is not found on the first list, the system checks whether the drug is on the second drug list. If the drug is found on the second drug list, the system then moves directly to the processing stage, etc. Preferably, the drug list hierarchy is as follows: (i) home infusion drug list; (ii) drug only listed as a Medicare Part B drug list; (iii) drug listed as either Medicare Part B or D drug list; (iv) required special class drug list; (v) nebulized drug list; (vi) over the counter drug list; (vii) Medicare statutorily excluded non-Part D drug list; (viii) enhanced benefit system drug list; (ix) Medicare Part D or Medicare Part D covered under an enhanced benefit drug list, and (x) a vaccine drug list.
1. A non-transitory computer-readable medium comprising instructions that when executed on at least one computer, cause the at least one computer to perform a method of sorting and processing drug claims, the method comprising:
(a) receiving a claim using the at least one computer;
(b) sorting the claim for processing by:
(i) determining if the claim is for a drug listed as a home infusion drug, and if not, then;
(ii) determining if the claim is for a drug that is only listed as a Medicare Part B drug, and if not then;
(iii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and if not then;
(iv) determining if the claim is for a drug that is listed as a required special class drug, and if not, then;
(v) determining if the claim is for a drug that is listed as a nebulized drug, and if not, then;
(vi) determining if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, and if not, then;
(vii) determining if the claim is for a drug that is listed as a Medicare statutorily excluded non-Part D drug, and if not, then;
(viii) determining if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, and if not, then;
(ix) determining whether the claim is for a drug that is listed as eligible for either Medicare Part D or Medicare Part D covered under an enhanced benefit system; and if so, then determining whether the drug has been previously determined to be covered under the enhanced benefit system for the particular patient associated with the claim; and
(c) processing the claim as follows:
(i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim;
(ii) if the claim is for a drug that is only listed as a Medicare Part B drug, then processing the claim as a Medicare Part B drug claim;
(iii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim;
(iv) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim;
(vi) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim;
(vii) if the claim is for a drug that is listed as a required special class drug, then processing the claim as a required special class drug claim;
(viii) if the claim is for a drug that is listed as a nebulized drug, then processing the claim as a nebulized drug claim;
(ix) if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, then processing the claim as an over the counter drug claim under Medicare Part D;
(x) if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, then, then processing the claim under an enhanced benefit system under Medicare Part D;
(xi) if the claim is for a drug that is listed as a Medicare Part D drug that is covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim under an enhanced benefit system under Medicare Part D; and
(xii) if the claim is for a drug that is listed as a Medicare Part D drug that is not covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim as a standard Medicare Part D drug claim.
2. The non-transitory computer-readable medium of claim 1 , wherein the method further comprises:
sorting the claim for processing by determining if the claim is for a drug previously determined to be a Medicare Part B drug for the particular patient associated with the claim prior to determining if the claim is for a drug listed as a home infusion drug.
3. The non-transitory computer-readable medium of claim 1 , wherein the method further comprises:
sorting the claim for processing by determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim after determining if the claim is for a drug that is listed as a nebulized drug.
4. The non-transitory computer-readable medium of claim 1 , wherein the method further comprises:
sorting the claim for processing by determining if the claim is for a drug that is listed as a vaccine, and if so, then;
processing the claim as a vaccine drug claim.
5. The non-transitory computer-readable medium of claim 1 , wherein processing the claim further comprises determining if a client will accept processing of the claim prior to approving payment for the claim.
6. The non-transitory computer-readable medium of claim 1 , wherein the method further comprises:
placing drugs onto the drug lists on the basis of lists provided by CMS.
7. The non-transitory computer-readable medium of claim 1 , wherein the method further comprises:
placing drugs onto the drug lists on the basis of lists devised by an operator of the system embodying the method of claim 1 .
8. The non-transitory computer-readable medium claim 7 , wherein the lists devised by the operator are constructed on the basis of formularies devised by the operator.
9. The non-transitory computer-readable medium claim 7 , wherein the lists devised by the operator are constructed on the basis of representative drug codes.
10. The non-transitory computer-readable medium of claim 1 , wherein the method further comprises:
periodically updating the drug lists.
11. The non-transitory computer-readable medium of claim 1 , wherein determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim comprises determining if a prior prescription authorization has been made for the particular patient associated with the claim.
12. The non-transitory computer-readable medium of claim 1 , wherein determining whether the drug has been previously determined to be a Medicare Part D drug or a Medicare Part D drug covered under an enhanced benefit system for the particular patient associated with the claim comprises determining if a prior prescription authorization has been made for the particular patient associated with the claim.
13. The non-transitory computer-readable medium of claim 1 , wherein processing the claim as a required special class drug claim comprises determining if the particular patient has previously received the drug.
14. The non-transitory computer-readable medium of claim 1 , wherein processing the claim as a required special class drug claim comprises determining whether the particular patient is in transition between different prescription plans.
15. The non-transitory computer-readable medium of claim 1 , wherein processing the claim as a nebulized drug claim comprises determining whether the particular patient is in a long term care facility.
16. The non-transitory computer-readable medium of claim 1 , wherein determining which drug list a drug is placed on comprises determining both the identity of the drug, and the drug's method of treatment.
17. The non-transitory computer-readable medium of claim 1 , wherein updating the drug lists comprises using data from at least one of CMS Part D Formulary Guidance, CMS Formulary Reference File Updates, CMS DESI (Drug Efficacy Study Implementation) Website, FDA resources, CMS Coverage Determinations via Prescription Drug Event (PDE) monitoring, and Durable Medical Equipment Regional Carriers.
18. The non-transitory computer-readable medium of claim 1 , wherein the step of determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug comprises using a formulary or representative drug code approach.
19. The non-transitory computer-readable medium of claim 18 , wherein proxies or other representative drug codes used in the formulary approach are devised by an operator.
20. The non-transitory computer-readable medium of claim 18 , wherein proxies or other representative drug codes used in the formulary approach are devised by a client of an operator.
21. A computerized system for sorting and processing drug claims, comprising:
(a) a computer for receiving a claim;
(b) a system for sorting the claim for processing by:
(i) determining if the claim is for a drug listed as a home infusion drug, and if not, then;
(ii) determining if the claim is for a drug that is only listed as a Medicare Part B drug, and if not then;
(iii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and if not then,
(iv) determining if the claim is for a drug that is listed as a required special class drug, and if not, then;
(v) determining if the claim is for a drug that is listed as a nebulized drug, and if not, then;
(vi) determining if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, and if not, then;
(vii) determining if the claim is for a drug that is listed as a Medicare statutorily excluded non-Part D drug, and if not, then;
(viii) determining if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, and if not, then;
(ix) determining whether the claim is for a drug that is listed as eligible for either Medicare Part D or Medicare Part D covered under an enhanced benefit system; and if so, then determining whether the drug has been previously determined to be covered under an enhanced benefit system for the particular patient associated with the claim; and
(c) a system for processing the claim as follows:
(i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim;
(ii) if the claim is for a drug that is only listed as a Medicare Part B drug, then processing the claim as a Medicare Part B drug claim;
(iii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim;
(iv) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim;
(vi) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim;
(vii) if the claim is for a drug that is listed as a required special class drug, then processing the claim as a required special class drug claim;
(viii) if the claim is for a drug that is listed as a nebulized drug, then processing the claim as a nebulized drug claim;
(ix) if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, then processing the claim as an over the counter drug claim under Medicare Part D;
(x) if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, then, then processing the claim under an enhanced benefit system under Medicare Part D;
(xi) if the claim is for a drug that is listed as a Medicare Part D drug that is covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim under an enhanced benefit system under Medicare Part D; and
(xii) if the claim is for a drug that is listed as a Medicare Part D drug that is not covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim as a standard Medicare Part D drug claim.
22. A non-transitory computer-readable medium comprising instructions that when executed on at least one computer, cause the at least one computer to perform a method of sorting and processing drug claims, the method comprising:
(a) receiving a claim using a computer;
(b) sorting the claim for processing by:
(i) determining if the claim is for a home infusion drug, and if not then;
(ii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining by a formulary or representative drug code approach whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and
(c) processing the claim as follows:
(i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim;
(ii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim;
(iii) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim, and
(iv) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim.
23. The non-transitory computer-readable medium of claim 22 , wherein proxies or other representative drug codes used in the formulary approach are devised by an operator.
24. The non-transitory computer-readable medium of claim 22 , wherein proxies or other representative drug codes used in the formulary approach are devised by a client of an operator.
25. The non-transitory computer-readable medium of claim 22 , wherein the method further comprises:
(d) sorting the claim for processing by determining if the claim is for a drug that is listed as one or more of the following:
(i) a required special class drug; or
(ii) a nebulized drug; or
(iii) an over the counter drug covered under a Medicare Part D administrative fee; or
(iv) a Medicare statutorily excluded non-Part D drug; or
(v) a Medicare Part D drug that is always covered under an enhanced benefit system; or
(vi) a drug that is listed as eligible for either Medicare Part D or Medicare Part D under an enhanced benefit system, and if so, then determining whether the drug has been previously determined to be a regular Medicare Part D drug or a Medicare Part D drug covered under an enhanced benefit system for the particular patient associated with the claim; and
(e) processing the claim as follows:
(i) if the claim is for a drug that is listed as a required special class drug, then processing the claim as a required special class drug claim;
(ii) if the claim is for a drug that is listed as a nebulized drug, then processing the claim as a nebulized drug claim;
(iii) if the claim is for a drug that is listed as an over the counter drug covered under a Medicare Part D administrative fee, then processing the claim as an over the counter drug claim under Medicare Part D;
(iv) if the claim is for a Medicare statutorily excluded non-Part D drug, then processing the claim as a Medicare statutorily excluded non-Part D drug claim;
(v) if the claim is for a drug that is listed as always being covered under an enhanced benefit system under Medicare Part D, then, then processing the claim under an enhanced benefit system under Medicare Part D;
(vi) if the claim is for a drug that is listed as a Medicare Part D drug that is covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim under an enhanced benefit system under Medicare Part D; and
(vii) if the claim is for a drug that is listed as a Medicare Part D drug that is not covered under an enhanced benefit system for the particular patient associated with the claim, then processing the claim as a standard Medicare Part D drug claim.
26. The non-transitory computer-readable medium of claim 22 , wherein processing the claim further comprises determining if a client will accept processing of the claim prior to approving payment for the claim.
27. The non-transitory computer-readable medium of claim 22 , wherein the method further comprises:
placing drugs onto the drug lists on the basis of lists provided by CMS.
28. The non-transitory computer-readable medium of claim 22 , wherein the method further comprises:
placing drugs onto the drug lists on the basis of lists devised by an operator of the system embodying the method of claim 22 .
29. The non-transitory computer-readable medium of claim 22 , wherein determining whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim comprises determining if a prior prescription authorization has been made for the particular patient associated with the claim.
30. The non-transitory computer-readable medium of claim 22 , wherein processing the claim as a required special class drug claim comprises determining if the particular patient has previously received the drug.
31. The non-transitory computer-readable medium of claim 22 , wherein processing the claim as a required special class drug claim comprises determining whether the particular patient is in transition between different prescription plans.
32. The non-transitory computer-readable medium of claim 22 , wherein processing the claim as a nebulized drug claim comprises determining whether the particular patient is in a long term care facility.
33. The non-transitory computer-readable medium of claim 22 , wherein determining which drug list a drug is placed on comprises determining both the identity of the drug, and the drug's method of treatment.
34. A computerized system for sorting and processing drug claims, comprising:
(a) a computer for receiving a claim;
(b) a system for sorting the claim for processing by:
(i) determining if the claim is for a home infusion drug, and if not then;
(ii) determining if the claim is for a drug that is listed as either a Medicare Part B or a Medicare Part D drug, and if so, then determining by a formulary-specific representative drug code approach whether the drug has been previously determined to be a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim; and
(c) a system for processing the claim as follows:
(i) if the claim is for a drug that is listed as a home infusion drug, then processing the claim as a home infusion drug claim;
(ii) if the claim is for a drug that is listed as a Medicare Part B drug that has previously been determined to be a Medicare Part B drug for the particular patient associated with the claim, then processing the claim as a Medicare Part B drug claim;
(iii) if the claim is for a drug that is listed as a Medicare Part D drug that has previously been determined to be a Medicare Part D drug for the particular patient associated with the claim, then processing the claim as a Medicare Part D drug claim; and
(iv) if the claim is for a drug that is listed as eligible for either Medicare Part B or Medicare Part D, and no previous determination has been made as to whether the drug is a Medicare Part B drug or a Medicare Part D drug for the particular patient associated with the claim, then rejecting the claim.