Dynamic Claims Adjudication for Personalized Copay Determination
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Solution Overview
Problem
Conventional prescription drug benefits management systems face challenges in dynamically adjudicating claims due to rigid drug classifications and copay structures, which do not account for individual member-specific criteria, leading to inflexible and inefficient copay determinations.
Innovation Solution
A dynamic claims adjudication system that analyzes member-specific criteria to determine the appropriate adjudication rule set for each claim, allowing for real-time adjustments in tier levels and copays based on factors such as step therapy, prior treatments, and other patient-specific events, thereby overcoming the limitations of traditional formulary-based systems.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If conventional formulary-based adjudication is used, then drug classification and copay determination are simplified, but the system becomes rigid and cannot account for individual member-specific criteria
Solution Approach 1:
The patent implements dynamic adjudication by allowing the system to transition from static formulary-based tier assignments to dynamic tier adjustments based on real-time analysis of member-specific criteria. The adjudication system dynamically modifies copay amounts and tier levels during claims processing based on factors such as step therapy compliance, prior treatments, and patient-specific events, thereby resolving the contradiction between adaptability and complexity.
Solution Approach 2:
The system changes key parameters (copay amounts, tier levels) from fixed values defined in the formulary to variable values determined through real-time analysis of member-specific criteria. This allows the same drug to have different copays for different members or even for the same member at different times based on their treatment history and compliance with step therapy protocols.
2Reliability
If rigid formulary tiers are enforced, then adjudication processing is faster and simpler, but individualized care and step therapy adherence are compromised
Solution Approach 1:
The system performs preliminary actions by pre-establishing adjudication rules, step therapy protocols, and member criteria profiles before claims processing. This allows the real-time adjudication system to quickly retrieve and apply pre-defined rules without extensive analysis during claims processing, thereby maintaining processing speed while enabling individualized care through pre-configured member-specific criteria.
3Ease of operation
If dynamic analysis of member-specific criteria is performed, then personalized copay determination is achieved, but system complexity and processing requirements increase
Solution Approach 1:
The patent segments the adjudication system into distinct functional modules: formulary lookup, member criteria retrieval, dynamic rule application, and copay calculation. Each module handles a specific aspect of the adjudication process, allowing the system to manage complexity through modular design while maintaining flexibility in copay determination through the coordinated interaction of these segments.
Data Source
AI summary
A dynamic claims adjudication system is provided that implements a dynamic claims adjudication process to provide flexible determination of the adjudication rule set to be used to adjudicate a claim for a particular prescription drug regardless of the mandates of the formulary and the rigidity of the tier into which the drug is placed on the formulary. The claims adjudication system and corresponding methods dynamically determine the adjudication rule set to be used to adjudicate a claim based on an analysis of criteria and identification of a tier changing criteria. Accordingly, the rigidity of conventional formulary based claims adjudication is eliminated in favor of dynamic and flexible real time claims adjudication.