Systems and methods for processing healthcare claim transactions that are rejected due to a host error

1. A computer-implemented method, comprising:

routing, to a claims processor computer, a healthcare claim transaction received from a healthcare provider computer;

receiving an adjudicated reply, from the claims processor computer, to the healthcare claim transaction;

responsive to a determination that the adjudicated reply indicates that the claim transaction was paid, route the adjudicated reply indicating that the claim was paid to the healthcare provider computer;

responsive to a determination that the adjudicated reply indicates that the claim transaction was not paid, further determining whether the healthcare claim transaction has not been approved as a result of a host processor error associated with the claims processor computer;

responsive to a determination that the claim has not been rejected as a result of a host processing error, route the adjudicated reply indicating that the claim was not paid to the healthcare provider computer;

responsive to a determination that the claim has not been approved as a result of a host processing error, perform the following steps:

identifying, based at least in part on the received adjudicated reply, a host processing error associated with the claims processor computer, wherein the host processing error includes at least one of an unresponsive host error, a high bandwidth error, or an unavailable host error;

further identifying a National Council for Prescription Drug Programs (NCPDP) reject code associated with the host processing error;

determining that the healthcare claim transaction has not been approved as a result of the identified host processor error associated with the claims processor computer;

determining that a value of an adjudication timer initiated by a pre-edit performed on the healthcare claim transaction prior to routing to the claims processor and associated with identifying the host processing error does not exceed a resubmission threshold, wherein the resubmission threshold is determined by subtracting an estimated healthcare claim processing time from an adjudication threshold; and

resubmitting, based at least in part on the determination that the healthcare claim transaction has not been approved and that the value of the adjudication timer does not exceed the resubmission threshold, the healthcare claim transaction to the claims processor computer;

receiving an adjudicated reply for the resubmitted healthcare claim transaction from the claims processor computer, and routing the received adjudicated reply to the healthcare provider computer,

wherein the above operations are performed by one or more computers associated with a service provider.

2. The computer-implemented method of claim 1 , wherein determining that the healthcare claim transaction has not been approved as the result of the host processing error further comprises identifying a timing out situation associated with the healthcare claim transaction.

3. The computer-implemented method of claim 1 , further comprising:

determining, based at least in part on the received adjudicated reply, that the resubmitted healthcare claim transaction has been rejected as a duplicate claim; and

altering a claim status of the adjudicated reply to a status indicating that the healthcare claim transaction has been approved.

4. The computer-implemented method of claim 1 , further comprising:

determining, based at least in part on the received adjudicated reply, that the resubmitted healthcare claim transaction has not been approved as a result of the host processor error associated with the claims processor computer; and

directing a second resubmission of the healthcare claim transaction to the claims processor computer.

5. The computer-implemented method of claim 4 , wherein directing the second resubmission of the healthcare claim transaction comprises:

accessing a value of a claims processing timer associated with the second resubmission of the healthcare claim transaction; and

determining, that the accessed value of the claims processing timer does not exceed a timer threshold.

6. The computer-implemented method of claim 1 , further comprising:

identifying a timing out situation associated with the resubmitted healthcare claim transaction;

generating a message indicating that the healthcare claim transaction has been rejected due to host processor error; and

communicating the generated message to the healthcare provider computer.

7. A system, comprising:

at least one memory operable to store computer-executable instructions; and

at least one processor configured to access the at least one memory and execute the computer-executable instructions to:

route, to a claims processor computer, a healthcare claim transaction received from a healthcare provider computer;

receive an adjudicated reply from the claims processor computer to the healthcare claim transaction;

responsive to a determination that the adjudicated reply indicates that the claim transaction was paid, route the adjudicated reply indicating that the claim was paid to the healthcare provider computer;

responsive to a determination that the adjudicated reply indicates that the claim transaction was not paid, further determining whether the healthcare claim transaction has not been approved as a result of a host processor error associated with the claims processor computer;

responsive to a determination that the claim has not been rejected as a result of a host processing error, route the adjudicated reply indicating that the claim was not paid to the healthcare provider computer;

responsive to a determination that the claim has not been approved as a result of a host processing error, perform the following steps:

identify, based at least in part on the received adjudicated reply, a host processing error associated with the claims processor computer, wherein the host processing error includes at least one of an unresponsive host error, a high bandwidth error, or an unavailable host error;

further identifying a National Council for Prescription Drug Programs (NCPDP) reject code associated with the host processing error;

determine that the healthcare claim transaction has not been approved as a result of the identified host processor error associated with the claims processor computer;

determine that a value of an adjudication timer initiated by a pre-edit performed on the healthcare claim transaction prior to routing to the claims processor and associated with identifying the host processing error does not exceed a resubmission threshold, wherein the resubmission threshold is determined by subtracting an estimated healthcare claim processing time from an adjudication threshold;

resubmit, based at least in part on the determination that the healthcare claim transaction has not been approved and that the value of the adjudication timer does not exceed the resubmission threshold, the healthcare claim transaction to the claims processor computer; and

receive an adjudicated reply for the resubmitted healthcare claim transaction from the claims processor computer, and routing the received adjudicated reply to the healthcare provider computer.

8. The system of claim 7 , wherein the at least one processor is operable to determine that the healthcare claim transaction has not been approved as the result of the host processing error by identifying a timing out situation associated with the healthcare claim transaction.

9. The system of claim 7 , wherein the at least one processor is further operable to execute the computer-executable instructions to:

determine, based at least in part on the received adjudicated reply, that the resubmitted healthcare claim transaction has been rejected as a duplicate claim; and

alter a claim status of the adjudicated reply to a status indicating that the healthcare claim transaction has been approved.

10. The system of claim 7 , wherein the at least one processor is further operable to execute the computer-executable instructions to:

determine, based at least in part on the received adjudicated reply, that the resubmitted healthcare claim transaction has not been approved as a result of the host processor error associated with the claims processor computer; and

direct a second resubmission of the healthcare claim transaction to the claims processor computer.

11. The system of claim 10 , wherein the at least one processor is operable to direct the second resubmission of the healthcare claim transaction by:

accessing a value of a claims processing timer associated with the second resubmission of the healthcare claim transaction; and

determining, that the accessed value of the claims processing timer does not exceed a timer threshold.

12. The system of claim 7 , wherein the at least one processor is further configured to execute the computer-implemented instructions to:

identify a timing out situation associated with the resubmitted healthcare claim transaction;

generate a message indicating that the healthcare claim transaction has been rejected due to host processor error; and

communicate the generated message to the healthcare provider computer.