SIMPLAN

     Claims transmitted from a pharmacy in-store computer through a data communication "switch", such as NDC, are received, processed and returned to the pharmacy by the TeleClaim system in just a few seconds. Tens of thousands of computations and decisions are made in an infinitesimal span of time ... and this enables thousands of claims being processed each working day.

     Therefore, it is critical that a newly implemented or changed TeleClaim benefit plan structure executes perfectly when first installed. Otherwise, the impact of just one small mistake can have repercussions that could cost tens of thousands of dollars before the mistake is detected. Even worse, a recipient of the prescription could be harmed due to an incorrect dispensing approval.

     "Working perfectly the first time" can only be accomplished with thorough, preliminary testing. SimPlan is the TeleClaim computer program that provides a user-friendly testing platform that allows an exhaustive examination of benefit plan computations prior to the plan structure being placed into production.

     This testing is a comprehensive simulation of an actual adjudication computation. The current and actual benefit member file, drug/price file, provider file, DUR files, etc. are used in the simulation to provide a completely accurate re-enactment of the adjudication process as it exists in production.

     The Plan Administrator can invoke SimPlan immediately after creating a new benefit plan structure with "PlanBuilder". He or she starts by entering the data of a real prescription. The computer then employs the exact copy of the adjudication algorithm and finishes processing by displaying the detail results of the adjudication.

     A comprehensive review of the input details and other aspects of computation enable a thorough analysis of the adjudication as seen in the accompanying sample: Figure 1.

     For example, the required data pertaining to the member profile is displayed as a confirmation for scrutinizing the integrity of computation using actual member parameters.

     All the key data elements available from the drug file are displayed for the user. The complete profile of drug parameters used in the computations may be confirmed as well.

     Prior related member refill history is also made available in the display. This becomes useful, particularly to rationalize intercepts like refill too soon, a drug interaction flag, and other prior related use by its member that effects the current prescription

     If a claim is rejected, the display provides enough data to ascertain the reason behind the rejection. NCPDP error messages and those generated by DUR would be displayed in this connection.