Process and system for the management, storage and automation of health care information and application program interface therefor

Abstract

A process for generating a response message to an eligibility verification request transmitted over a healthcare claims network having at least one health care protocol of communication comprises the steps of: executing business rules on a rules engine for a program sponsor on information in the eligibility verification request to determine an individual's eligibility for benefits; generating a protocol-compliant response message including information not specified in the health care protocol of communication; and providing the protocol-compliant response message to the claims network; wherein the at least one health care protocol of communication comprises the NCPDP Telecommunication Standard.

What is claimed is: 
     
         1 . A process for generating a response message to an eligibility verification request transmitted over a healthcare claims network having at least one health care protocol of communication, the process comprising the steps of:
 executing business rules on a rules engine for a program sponsor on information in the eligibility verification request to determine an individual's eligibility for benefits;   generating a protocol-compliant response message including information not specified in the health care protocol of communication; and   providing the protocol-compliant response message to the claims network;   
       wherein the at least one health care protocol of communication comprises the NCPDP Telecommunication Standard. 
     
     
         2 . The process of  claim 1 , wherein the information not specified in the health care protocol of communication comprises a coupon for pharmaceutical manufacturer benefits in a pre-defined field of the NCPDP Telecommunication Standard. 
     
     
         3 . The process of  claim 2 , wherein the coupon comprises at least a member ID personalized number for entry into a subsequent request for payment. 
     
     
         4 . The process of  claim 1 , wherein the protocol-compliant eligibility verification request message is generated on a first software solution and the protocol-compliant response message is generated by a second software solution; and wherein the second software solution further comprises a remote web portal. 
     
     
         5 . The process of  claim 4 , wherein the information not specified in the health care protocol of communication comprises a tokenized Uniform Resource Locator (URL) in the 526-FQ field of the NCPDP Telecommunication Standard which provides access to the remote web portal. 
     
     
         6 . The process of  claim 5 , wherein the rules engine determines that additional information is required to process the eligibility verification request, the web portal is pre-populated with information from the eligibility verification request from the rules engine, and wherein the tokenized URL includes information to authenticate a recipient of the URL and provide access to the web portal for a limited period of time. 
     
     
         7 . The process of  claim 5 , wherein the tokenized URL provides access to request-specific forms, including ability to pre-fill the forms based on claims data from the eligibility verification request, facilitate the transmission of the forms to stakeholders for review, and track the completion of various forms. 
     
     
         8 . The process of  claim 5 , wherein the tokenized URL enables collection and management of legal documents pertaining to a pharmaceutical manufacturer benefit program, place of service, or per-patient prescription transactions. 
     
     
         9 . The process of  claim 5 , wherein the tokenized URL enables place of service identity and licensure profiling. 
     
     
         10 . The process of  claim 5 , wherein the tokenized URL provides access to place of service training related to the eligibility verification request, inclusive of the provision of messaging, digital files, video and audio content pertaining to a payor-sponsored service. 
     
     
         11 . The process of  claim 5 , wherein the tokenized URL enables intake of data files comprising information not captured via a standard NCPPD eligibility verification request. 
     
     
         12 . The process of  claim 5 , wherein the tokenized URL enables guided conveyance of forms for the processing and electronic filing of prior authorization forms by pharmacies for patients in connection with manufacturer-sponsored service programs 
     
     
         13 . The process of  claim 4 , wherein the first software solution is a healthcare services Provider's claim processing system, and further comprising the step of displaying at the first software solution to the Provider a response. 
     
     
         14 . The process of  claim 4 , wherein a benefit program administrator operates the second software solution, and the benefit program administrator receives and parses the protocol compliant eligibility verification request message. 
     
     
         15 . The process of  claim 14 , wherein benefit program administrator is assigned routing information comprising at least one of the group comprising a Bank Identification Number (BIN), a Process Control Number (PCN) and a Primary Group ID; and the protocol-compliant eligibility verification request message includes the assigned routing information. 
     
     
         16 . The process of  claim 4 , wherein the second software solution comprises an API, and the method further comprising the steps of:
 the API parsing the protocol-compliant eligibility verification request message into a machine-readable object,   the business rules engine executing the business rules on the machine readable object;   the business rules engine updating the machine-readable object with response information; and   the API generating the protocol-compliant response message based on the updated machine-readable object.   
     
     
         17 . The process of  claim 1  further comprising the step of parsing the protocol-compliant eligibility verification request message to extract information relevant to a pharmaceutical manufacturer benefit program, wherein step of parsing the protocol-compliant eligibility verification request message is performed by a program sponsor and the step of executing business rules by is performed by a program administrator. 
     
     
         18 . The process of  claim 1  further comprising the step of receiving the protocol-compliant eligibility verification request message from the claims network. 
     
     
         19 . The process of  claim 1 , wherein the program sponsor is a pharmaceutical manufacturer. 
     
     
         20 . The process of  claim 1 , wherein the program sponsor is an insurer. 
     
     
         21 . A process for generating a response message to an eligibility verification request transmitted over a healthcare claims network having at least one health care protocol of communication, the process comprising the steps of:
 executing business rules on a rules engine for a program sponsor on information extracted from the eligibility verification request to determine an individual's eligibility for benefits;   populating a web portal with information extracted from the eligibility verification request; and   providing a response to the eligibility verification request via the web portal and over a network other than the healthcare claims network;   
       wherein the at least one health care protocol of communication comprises the NCPDP Telecommunication Standard. 
     
     
         22 . The process of  claim 21 , wherein the protocol-compliant eligibility verification request message is generated on a first software solution and the business rules engine and web portal comprise a second software solution. 
     
     
         23 . The process of  claim 21 , wherein the business rules engine determines that additional information is required to process the eligibility verification request, the web portal is pre-populated with information from the eligibility verification request from the rules engine, and wherein web portal communicates a request for additional information to an individual without using the healthcare claims network. 
     
     
         24 . The process of  claim 23 , wherein the first software solution is a healthcare services Provider's claim processing system. 
     
     
         25 . The process of  claim 23 , wherein a benefit program administrator operates the second software solution, and the benefit program administrator receives and parses the protocol compliant eligibility verification request message. 
     
     
         26 . The process of  claim 25 , wherein benefit program administrator is assigned routing information comprising at least one of the group comprising a Bank Identification Number (BIN), a Process Control Number (PCN) and a Primary Group ID; and the protocol-compliant eligibility verification request message includes the assigned routing information. 
     
     
         27 . The process of  claim 23 , wherein the second software solution comprises an API, and the method further comprising the steps of:
 the API parsing the protocol-compliant eligibility verification request message into a machine-readable object,   the business rules engine executing the business rules on the machine readable object;   the business rules engine updating the machine-readable object with response information; and   the business rules engine populating the web portal with information based on the updated machine-readable object.   
     
     
         28 . The process of  claim 21  further comprising the step of receiving the protocol-compliant eligibility verification request message from the healthcare claims network. 
     
     
         29 . The process of  claim 21 , wherein the program sponsor is a pharmaceutical manufacturer. 
     
     
         30 . The process of  claim 21 , wherein the program sponsor is an insurer. 
     
     
         31 . The process of  claim 21 , further comprising the step of receiving the response on a mobile device. 
     
     
         32 . The process of  claim 21 , further comprising the step of receiving the response on a mobile device, wherein the mobile device is associated with a person selected from the group consisting of a prescribing physician, a pharmacist, and a patient related to the eligibility verification request. 
     
     
         33 . The process of  claim 1  further comprising the step of parsing the protocol-compliant eligibility verification request message to extract information relevant to a wellness program sponsored by a third party payor, pharmaceutical manufacturer benefit program, or other third party, wherein step of parsing the protocol-compliant eligibility verification request message is performed by a program sponsor and the step of executing business rules by is performed by a program administrator.