System and method for seamless prescription medication discounting
A system and method for a seamless provision of discounting for prescription services that are not eligible for financial coverage by a plan, such as a Medicare Part D plan. The system and method take denials from Pharmacy Benefit Managers (PBMs) and seamlessly provides to end users (patients) a discounted cost for the denied coverage of the prescription. Denials of coverage are transmitted to a switch server where rejection codes are detected at the switch server and relayed to the seamless server. The seamless server then provides an approval instead of the original PBM.
1 . A method for seamless provision of discount prescription information executed by a networked claims processing system comprising a pharmacy server, a switch server, a seamless server, and at least one discount server, comprising:
transmitting prescription data from a pharmacy server to a switch server;
transmitting the prescription data from the switch server to a pharmacy benefit manager (PBM) server;
determining at the PBM server if financial coverage will be provided based on the prescription data;
transmitting a rejection code to the switch server if it is determined that coverage will not be provided;
at the switch server, computing an eligibility score from a plurality of rejection codes by applying a weighting model that assigns different weights to respective rejection codes and comparing a sum of the weights to a threshold, and processing the plurality of rejection codes at the switch server to determine if the plurality of rejection codes corresponds to an actionable claim;
responsive to the eligibility score satisfying the threshold, generating by the switch server, an edited claim that replaces original routing fields with destination information for sending the patient information and the medication information, wherein the destination information is at least one discount server, the destination information comprising a BIN, a PCN, and a GroupID identified by the seamless server;
invoking, by the switch server, an application programming interface (API) of the seamless server with at least the plurality of rejection codes, GPI and/or NDC of the medication, and cost parameters;
receiving, from the seamless server, the BIN/PCN/GroupID associated with a discount server selected according to a deterministic selection policy that prioritizes lowest cash price and, when prices are equal, applies a server-specific rank;
routing the patient information and the medication information using the edited claim to the selected discount server without user re-entry of the prescription data;
determining confirmation of coverage at the discount server using the patient information and the medication information;
transmitting from the discount server to the switch server confirmation of coverage; and
transmitting from the switch server to the pharmacy server the confirmation of coverage, wherein the transmitting includes updating a transaction state at the seamless server and notifying the PBM server of cash-price adjudication or reversal, thereby reducing repeated network round-trips and resubmissions.
2 . The method of claim 1 , wherein there is more than one discount server.
3 . The method of claim 2 , wherein computing the eligibility score comprises summing weights to rejection codes and comparing the sum to a threshold to determine actionability.
4 . The method of claim 1 , wherein at least one of the plurality of rejection codes is determined based on the medication information.
5 . The method of claim 1 , wherein wherein not all of the plurality of rejection codes are transmitted to the seamless server.
6 . The method of claim 1 , wherein the prescription data comprises financial coverage information, patient information, and medication information.
7 . The method of claim 1 , wherein a claim reversal is sent to the seamless server and the PBM server is notified of the claim reversal.
8 . The method of claim 1 , further comprising transmitting confirmation of coverage to the seamless server in addition to transmitting confirmation of coverage to the switch server.
9 . The method of claim 1 , wherein more than one rejection code is generated for the prescription data.
10 . The method of claim 9 , wherein each of the more than one rejection code is determined to be actionable by the discount server.
11 . A system for seamless provision of discount prescription information comprising:
a pharmacy server adapted to receive and transmit prescription data;
a switch server operably connected to the pharmacy server, wherein the switch server is adapted to receive and transmit prescription data and configured to: (i) parse a plurality of rejection codes returned by a PBM server; (ii) compute an eligibility score by applying code-specific weights; (iii) compare the eligibility score to a threshold; and (iv) when the threshold is satisfied, generate an edited claim with a BIN/PCN/GroupID selected by a seamless server;
a pharmacy benefit manager (PBM) server adapted to receive prescription data and generate a rejection code set based in part on the prescription data;
a seamless server adapted to receive processed rejection codes and GPI and/or NDC identifiers from the switch server and processed by the switch server and based on a deterministic selection policy that prioritizes lowest cash price and applies server-specific rank for tie-breaking return destination data comprising a BIN/PCN/GroupID of a discount server;
a discount server adapted to provide confirmation of coverage to the switch server and to provide transaction acknowledgments to the seamless server to the PBM server during cash-price transactions and reversals, thereby reducing re-keying at the pharmacy server and decreasing adjudication latency.
12 . The system of claim 11 , wherein computing the eligibility score comprises summing weights to rejection codes and comparing the sum to a threshold to determine actionability.
13 . The system of claim 12 , wherein the seamless server is adapted to process the rejection code to determine which discount server to provide destination information to.
14 . The system of claim 13 , wherein at least one of the rejection codes is determined based on the medication information.
15 . The system of claim 11 , wherein not all rejection codes are transmitted to the seamless server.
16 . The system of claim 11 , wherein the prescription data comprises financial coverage information, patient information, and medication information.
17 . The system of claim 11 , wherein the pharmacy server is cloud-based.
18 . The system of claim 11 , wherein the discount server is adapted to provide confirmation of coverage to the seamless server in addition to the switch server.
19 . The system of claim 18 , wherein more than one rejection code is generated for the prescription data.
20 . The system of claim 19 , wherein each of the more than one rejection code is determined to be actionable by the discount server.