Medimpact Healthcare Systems, Inc.

Frederick Howe

William J Barre

Dale R Brown

Michael W Lyon

Paul M Momita

A method for electronically determining patient medical treatment eligibility, coverage, copayment amount and insurer billing simultaneously, by: (a) a patient requesting medical treatment at a retail clinic; (b) the patient presenting a health insurance card at the retail clinic; (c) the retail clinic transmitting patient health insurance card information to a centralized adjudication facility; (d) the retail clinic transmitting medical treatment information to the centralized adjudication facility; (e) the centralized adjudication facility determining patient medical treatment coverage, eligibility and copayment amount (f) transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic; (g) the patient purchasing the medical treatment by paying the retail clinic the copayment amount, (h) transmitting a bill to the health care insurance provider; and (i) thereby informing the retail clinic clinician to sell the medical treatment to the patient.

System for processing retail clinic claims

Systems, devices, non-transitory computer storage mediums, and methods are described herein for pharmaceutical benefits management including routing pharmaceutical claims over a computer network. The system includes a computer network and a client device communicatively coupled to the computer network. The client device is configured to receive order information representative of a prescription drug prescribed for a consumer. The system includes a communications switch configured to derive a processor control number associated with the order information and route the order information based on the processor control number. The system includes a pharmaceutical benefits manager configured to authorize the prescription drug with the reimbursement based on the processor control number and configured to transmit the authorization with the reimbursement to the client device.

Pharmaceutical benefits management

A method is disclosed whereby consumers enrolled in a prescription benefit plan can obtain prescription medication fulfillment at any participating pharmacy of their choice, regardless of whether the fulfillment is by a retail pharmacy or a mail order pharmacy, and whether the quantity of medication prescribed is for administration over a short period (acute care) or a prolonged period (maintenance). The plan of this invention operates by having the plan manager substantially equalize the financial effects of the discounts and services fees allowed to participating pharmacies such that both retail and mail order pharmacies are compensated in a manner which encourages them to accept all consumers and fill all prescriptions. Compensation is preferably adjusted periodically by the manager to retain pharmacy incentives. Consumers obtain choice of pharmacies, plan payers have pleased employees and members and pharmacies obtain income from the entire spectrum of consumers.

Method for providing consumer choice and equalizing pharmacy provider availability in prescription medication dispensing plans

A method for electronically determining patient medical treatment eligibility, coverage, copayment amount and insurer billing, by: (a) a patient requesting medical treatment at a retail clinic; (b) the patient presenting a health insurance card at the retail clinic; (c) the retail clinic transmitting patient health insurance card information to a centralized adjudication facility; (d) the retail clinic transmitting medical treatment information to the centralized adjudication facility; (e) the centralized adjudication facility determining patient medical treatment coverage, eligibility and copayment amount (f) transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic; (g) the patient purchasing the medical treatment by paying the retail clinic the copayment amount, (h) transmitting a bill to the health care insurance provider; and (i) thereby informing the retail clinic clinician to sell the medical treatment to the patient. By simultaneously billing the patient and the insurer, the present invention provides a system that processes the sale of the medical treatment as a sales transaction.

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.

System for pre-processing drug benefit claims according to processed drug lists

A method is disclosed by which pharmacies and physicians are encouraged to select appropriate and effective medications but dissuaded from selecting higher priced medications where more economical versions are available as alternatives, but where physicians and patients can also select such higher priced medications if they so choose and are prepared to pay that higher price. Under this system a single representative price (capitation rate) is calculated by a prescription payment plan manager for a group of related medications, usually including both branded and generic, and that price is paid to a pharmacy for all prescriptions of that group of medications fulfilled under the plan. The representative prices for different groups, including their minimum levels, are periodically reviewed and updated as appropriate.

Growing community of inventors

Rancho Santa Fe, CA, United States of America

Frederick Howe