Pharmacy Adjudication Orchestration Layer for Claim Processing
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Solution Overview
Problem
Conventional prescription drug claims adjudication systems face challenges in processing a large volume of claims within reasonable delays due to complexity and dependencies between rules, limiting flexibility and increasing costs.
Innovation Solution
An electronic pharmacy adjudication system with multiple interdependent layers, including an interface layer, orchestration layer, and service and rules engine layer, which processes healthcare insurance claims by generating a sequence of service calls to derive partial decision results, allowing for efficient adjudication decisions and flexibility in rule application.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If conventional rules-based decision management systems are used to process claims, then adjudication decisions can be generated, but the system performance becomes unsatisfactory and processing delays occur due to rule complexity and dependencies
Solution Approach 1:
The patent segments the adjudication system into multiple independent service layers (eligibility service, benefit service, cost service, etc.), each responsible for specific adjudication tasks. This segmentation allows parallel processing of claims across different services, significantly improving productivity while reducing the complexity of individual rule sets through modular organization.
Solution Approach 2:
The patent transitions from a single-layer rules-based decision management system to a multi-layer orchestration architecture. By adding the dimension of service layering and orchestration coordination, the system can process claims more efficiently through parallel service execution while maintaining comprehensive adjudication capabilities.
2Reliability
If comprehensive rules are applied to cover all possible claim scenarios, then adjudication accuracy is maintained, but processing time increases and flexibility to modify rules is reduced
Solution Approach 1:
The patent implements dynamic rule selection where the orchestration layer determines which services to invoke based on claim characteristics. This allows the system to adapt the scope of rule application dynamically - using comprehensive rules only when necessary while employing simplified processing for common cases, thereby maintaining accuracy without unnecessary processing time.
Solution Approach 2:
The system performs preliminary eligibility verification through the eligibility service before proceeding to more complex benefit and cost adjudication. This preliminary action filters out ineligible claims early, reducing the processing time for subsequent services while maintaining comprehensive coverage for eligible claims.
3Adaptability or versatility
If multiple service calls are made to process different aspects of a claim, then adjudication comprehensiveness is improved, but system complexity and processing overhead increase
Solution Approach 1:
The patent creates a universal orchestration layer that coordinates multiple services with standardized interfaces. This universal layer handles claim routing, result aggregation, and exception management across all services, reducing overall system complexity despite the multi-service architecture. Each service remains focused on its specific function while the orchestration layer provides unified coordination.
Solution Approach 2:
The orchestration layer acts as an intermediary between the claim processing initiators and the various adjudication services. It manages the complexity of coordinating multiple service calls, handling their results, and generating comprehensive adjudication decisions, thereby simplifying the overall system architecture despite the multi-service approach.
Data Source
AI summary
An electronic pharmacy adjudication system and associated method and computer program product for performing adjudication service for a healthcare insurance claim is provided. The system includes an interface layer, an orchestration layer and a service and rules engine layer configured for receiving, processing and releasing an adjudication decision. The orchestration layer processes the healthcare insurance claim to generate a sequence of service calls to the service and rules engine layer to derive a sequence of partial decision results, which are derived by processing a set of parameters identified by the service call according to a corresponding subset of decisions rules in a rules repository. The sequence of partial decision results is then processed to derive the adjudication decision corresponding to the healthcare insurance claim.