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The discussion will cover a standard TeleClaim configuration:

• Reports Workstation has its files resident on the file server
• The adjudicator has copies of its data files locally.

The diagram below, represents the transaction data flow of a client Rx to the Teleclaim system using a communication network (NDC, GCC, Envoy, etc) via an x.25 or a TCP/IP protocol. The only difference between the two network protocols being used (x.25 and TCP/IP) is the equipment interface to the Front End Processor. The x.25 uses an x.25 Packet Assembler/Disassembler (PAD) while the TCP/IP uses a router which could be connected to the internet and has it’s own IP (Internet Protocol) address. The Front End Processor using the x.25 protocol runs on a Windows 98 Operating System and the TCP/IP network based Front End Processor runs on a Windows NT 4.0 Workstation OS.

The client presents his prescription to a pharmacy. The pharmacist then keys in this prescription and other details from the client into his terminal. This data is then transmitted over to a network that processes this claim. Enclosed in the claim is a processor ID which the network uses to route back this claim to the corresponding pharmacy terminal. The processor handles the validation of this claim and sends the result back to the pharmacy. Based on this response, the pharmacist has the option to accept the prescription or reject it.

The format of the claim and its associated response is given by NCPDP (National Council for Prescription Drug Program). The DPRX Teleclaim System accepts version 3A, 3B and 3C of the NCPDP protocol.

The network routes the claims received from the pharmacy terminal to a Claims Processor based on the Processor ID embedded in the claim packet. Reponses from the processor are routed back to the initiating pharmacy. DPRX has the ability to install a network for a host system to all pharmacies in the network.

The turn around for this claim should be less than 10 seconds. If the claim takes more than 10 seconds, the network then transmits a Non-acknowledgement to the pharmacy and the pharmacy must try to re-transmit the claim. The actual processing of the claim takes less than 1 second. The claims coming form the pharmacy are sent to the processor via an x.25 or TCP/IP based network. Protocol used by the processor and the network is called the VISA protocol.

The diagram below represents the VISA Protocol.

• The network waits for a <ENQ> (Inquire Character) from the provider
• Upon receipt of a <ENQ>, the network then sends the claim in the format <STX>[MESSAGE]<ETX><LRC>.
• If the network receives a <NAK> (Non-Acknowledgement) from the provider, it then re-transmits the message in step 2. If the <LRC> calculation obtain by the provider is wrong, the Provider transmits a <NAK>.
• If a <NAK> is not received, then the packet is a response. The response is the same format as that given in step 2. The <LRC> is verified, if it is OK, then it is sent over the Pharmacy and a <ACK> is transmitted to the Provider. If the <LRC> is bad, a <NAK> is transmitted to the Provider and the network waits for the provider to re-transmit again.

The DP/Rx TeleClaim System is an interactive solution for a pharmacy provider. It accomplishes the Online processing of claims via a Network of PC’s. For systems using a Communication Network via x.25, the TeleClaim system starts from the x.25 PAD. For TCP/IP transactions, the ISDN modem/Router is the starting point.

x.25 PAD (Packet Assembler/Disassembler)

Converts the x.25 transmission and de-multiplexes the packet. Each packet is routed over to serial ports which are interfaced to the Front End Processor. The FEP (Front End Processor) has a minimum of 8 serial ports using an 8 port Digiboard.

A dedicated PC that polls the x.25’s serial ports (or listen to it’s TCP/IP port). Waits for an incoming transaction and sends it over to the Adjudicator via the VISA protocol. The incoming transactions are queued in the Front End Processor. The FEP then validates a claim via <LRC> calculation. If the calculation is faulty, the FEP then retransmits a NAK (Non-acknowledgement) to the serial port and back to the communication center. Otherwise, this is a valid claim placed on the FEP (Front End Processor) internal queue to be transmitted to the Adjudicator. This incoming claim that has a format of <STX>[MESSAGE]<ETX><LRC> is appended with a header containing <SOH>’FEP’[ID]<ETB>. The format of the message transmitted over to the Adjudicator is

The Adjudicator replies in the same format (its reply is stored in the message).

Transmission between the Front End Processor and Adjudicator is done through Shared Files on the FILE SERVER. The Operating System environment variable ‘FEPPATH’ points to the location of the files ‘CLAIM.FEP’ (claims written by the Front End Processor) and ‘REPLY.FEP’ (reply written by the Adjudicator).

The Front End Processor serves also as a bridge with the Reports Machine Workstations in the update of the Adjudicator’s local database. The Reports Machine transmits a TeleClaim "update record packet" via a file called "INQUIRY.FEP". The location of the file is given by the Operating System environment variable called ‘FEPPATH’. The Front End Processor searches for this file on the network during the scanning of its serial ports and puts this packet in its queue. The adjudicator, upon receipt of this packet updates a database record and sends its response back to the Front End Processor. The FEP writes out its response in ‘INQREPLY.FEP’. For a list of Adjudicator local databases which are updated, please refer to the ‘Adjudicator Processing’.

The adjudicator is a dedicated PC that processes the claim (from the Front End Processor) and update record packets (sent by the Reports Machine) from the Front End Processor. These transactions are all done via shared files on the FILE SERVER: ‘CLAIM.FEP’ and ‘REPLY.FEP’. The location of these files is given in the Operating

System environment variable named ‘FEPPATH’.

Hierarchical Levels in DP/Rx Adjudication of Claims

To have a better understanding of how the DP/Rx Adjudicator processes claims, a diagram is provided below that illustrates the different hierarchical conventions that DP/Rx uses in processing claims:

The current version of the Adjudicator uses local files in validating and processing claims. This ensures faster processing speed. The claims process today and their results are written on a shared file "TODAY.LOG" in the directory TRANSACT on the File Server. The Reports machine uses "TODAY.LOG" in querying today’s claims. 

The table below lists the directories, that the Adjudicator uses on its local drive.

Client Master File

Current Month Chronological Log File of Claims

The following table represents the Adjudicator transactions that are available to the Reports Machine. These modules were included in the system to enable the Teleclaim user to update the Adjudicator Master file online. The usual update procedure is that the File Server Master files are updated by the Reports Machine Workstation. These Master files are copied over to the Adjudicator Local Drive at Midnight (refer to Daily Cycle Procedure).

Online Transactions for the Adjudicator from the Reports Machine

• Maintain Member File
• Maintain Drug File
• Maintain Preferred Drug File
• Maintain Client File
• Maintain Group File
• Maintain Group Workers Comp
• Maintain Chain File
• Maintain Pharmacy File
• Maintain Physician File
• Maintain Account File
• Maintain Prior Authorization File
• Maintain Benefits Adjustment File
• Maintain Plan File
• Process Manual Claims

The reports machine workstation has the following capabilities:

• Used by the Help Desk in inquiring claims
• Inquiry and Maintenance of the files in the File Server and the Adjudicator
• Generation of reports to produce statistical or financial report. Reports are first spooled to disk and a separate a Teleclaim program allows the user to view the report, print it out on paper or on a tape or CD.
• Financial Processing
• The ability to produce checks to pharmacies and/or members based on the incoming claims.
• Conversion of Master Files to SDF files. As added functionality, the user is provided an option to export the TeleClaim Master and/or Transaction files into SDF (Standard Data File Format) this allows the user the ability to import data on his or her favorite database or spreadsheet package.
• DUR Drug Utilization retrospective analysis. Reports and analysis of Client’s Historic data. Includes drug interaction. Drug usage summary, etc.

Table below list Files contained in the \TRANSACT directory. These are only used by the Reports Workstation. Please note that files in \TRANSACT directory in the Adjudicator are also present in the File Servers \TRANSACT Directory.

Drugs with Mandated Generic Prices

Daily Cycle
The following Diagram illustrates the Daily Nightly Cycle initiated at 12:00 p.m. by the Adjudicator.

At 12:00 P.M. the Adjudicator begins to copy all the contents of the directory \MASTFILE on the File Server to its Local Drive. It then copies all files in Directory \TRANSACT from the Adjudicator’s Local file to the \ADJUD directory on the File Server. Upon completion, it then creates a file \ADJUD\READY. This file \ADJUD\READY is used by a Reports Machine Workstation to commence copying all files from the ‘ADJUD directory to \TRANSACT in the File Server. Upon completion of the transfer process the Reports Machine Workstation then creates the previous day file for inquiry. Upon creation of the file \ADJUD\READY the Adjudicator has an option to back up all its files on tape and then commences processing of on line claims. Upon Completion of the Reports Machine Processing, it is advised that the Network administrator uses its own File Server backup utility to commence backing up all the File Server files.

The month end cycle first initiates a daily cycle. At the start of a new month, claims are archived to the \HISTORY and \INQUIRY directory. Note also, that the online detail files stored in the Adjudicators \TRANSACT directory, are copied to the \lastmth direcoory, then purged signaling the beginning of a new month. This enables faster processing in the Adjudicator machine.

The TeleClaim System provides an export utility program that translates its databases into formats used by other Database(Oracle, Sybase, dBase, etc.) or Spreadsheet applications (Excel, Lotus, etc). This allows the users to create their own ad hoc reports and/or produce their own graphs.