Adjudication Subsystem Using Universal Patient Identifier
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Solution Overview
Problem
Current claim adjudication systems for prescription drug benefits face inefficiencies in verifying member eligibility, determining co-pays, and managing drug utilization reviews across multiple benefit plans, leading to incomplete patient profiles and potential degradation in healthcare quality.
Innovation Solution
A system and method for claim adjudication that includes a member device, pharmacy benefit manager device, and healthcare provider device, utilizing an adjudication subsystem with modules for drug benefit plan management, claims data access, prescription identification, adjudication operations, coverage checks, and notifications, which enables seamless communication and data integration across multiple benefit plans using a universal identifier.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If traditional claim adjudication systems are used to verify member eligibility and determine co-pays, then the adjudication process can be completed, but the system suffers from inefficiencies and incomplete patient profiles across multiple benefit plans
Solution Approach 1:
The system segments patient information management by creating separate patient information records for each benefit plan while using a universal patient identifier to link them. This allows the system to maintain comprehensive patient profiles across multiple benefit plans without information loss, while enabling efficient adjudication operations by organizing data in manageable segments.
Solution Approach 2:
The system implements a universal patient identifier that functions across multiple benefit plans and adjudication systems. This universal identifier enables the system to access and integrate patient information from different benefit plans, creating complete patient profiles while improving adjudication efficiency through unified access points.
2Adaptability or versatility
If multiple benefit plans are managed separately in traditional systems, then each plan can be administered independently, but patient profiles become incomplete and healthcare quality degrades
Solution Approach 1:
The system adds a new dimension to benefit plan management by implementing a multi-dimensional data structure that maintains separate benefit plan information while integrating them through a universal patient identifier. This allows independent administration of each benefit plan while simultaneously providing a comprehensive view of patient information across all plans, ensuring both flexibility and reliability.
Solution Approach 2:
The universal patient identifier acts as an intermediary that connects multiple benefit plans and their respective patient information records. This intermediary enables the system to maintain the independence and flexibility of separate benefit plan administrations while integrating patient information across plans to ensure complete profiles and high-quality healthcare delivery.
3Speed
If real-time adjudication operations are implemented, then claim processing speed improves, but system complexity increases
Solution Approach 1:
The system performs preliminary actions by pre-establishing patient information records for each benefit plan and creating the universal patient identifier framework before adjudication operations begin. This preliminary organization of data structures and relationships enables real-time adjudication processing without requiring complex runtime computations, thus improving speed while managing system complexity.
Data Source
AI summary
Methods and systems for claim adjudication are described. In one embodiment, a status of a drug benefit plan associated with a member is determined. Claims data associated with the member is accessed. A current-filled prescription is identified based on the claims data. At least one adjudication operation for the current-filled prescription is performed prior to receiving a new request for the current-filled prescription. The new request is determined as fillable based on the performance of the at least one adjudication operation. A notification is generated to the member based on the determination. Additional methods and systems are disclosed.