System and method for dynamic healthcare insurance claims decision support
First Claim
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1. A method for healthcare claim decision support, comprising:
- providing a computer with a processor, memory and a plurality of computer instructions configured to;
receive streaming transactional healthcare claim data;
extract a healthcare eligibility data stream, a healthcare claim submission data stream and a healthcare claim payment data stream from the streaming transactional healthcare claim data;
aggregate a message from the healthcare eligibility data stream, a message from the healthcare claim submission data stream and a message from the healthcare claim payment data stream about a particular claim being submitted to a payer;
perform a sliding window analysis to the aggregated messages about the particular claim being submitted to the payer to identify healthcare claim data in the aggregated messages that is relevant to the particular claim being submitted to the payer;
perform a frequent item set process on the identified healthcare claim data to determine a procedure code in the aggregated messages that does not match a service code;
perform a price analysis of the identified healthcare claim data in the aggregated messages to identify a price for a service or procedure in the claim that is abnormal for the payer;
perform a code co-occurrence of the identified healthcare claim data in the aggregated messages to identify two procedure codes that are not allowed in the same claim by the payer; and
generate user interfaces that show, for the particular claim to the payer, one or more issues with the claim based on the procedure code that does not match the service code, the price that is abnormal for the payer and two procedure codes that are not allowed in the same claim by the payer.
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Abstract
A healthcare claims processing and decision support system and method are disclosed that allow for the pre-processing of the healthcare claims as well as a method to reduce much of this overhead and alerting the user to any errors that occur during the claims processing.
134 Citations
14 Claims
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1. A method for healthcare claim decision support, comprising:
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providing a computer with a processor, memory and a plurality of computer instructions configured to; receive streaming transactional healthcare claim data; extract a healthcare eligibility data stream, a healthcare claim submission data stream and a healthcare claim payment data stream from the streaming transactional healthcare claim data; aggregate a message from the healthcare eligibility data stream, a message from the healthcare claim submission data stream and a message from the healthcare claim payment data stream about a particular claim being submitted to a payer; perform a sliding window analysis to the aggregated messages about the particular claim being submitted to the payer to identify healthcare claim data in the aggregated messages that is relevant to the particular claim being submitted to the payer; perform a frequent item set process on the identified healthcare claim data to determine a procedure code in the aggregated messages that does not match a service code; perform a price analysis of the identified healthcare claim data in the aggregated messages to identify a price for a service or procedure in the claim that is abnormal for the payer; perform a code co-occurrence of the identified healthcare claim data in the aggregated messages to identify two procedure codes that are not allowed in the same claim by the payer; and generate user interfaces that show, for the particular claim to the payer, one or more issues with the claim based on the procedure code that does not match the service code, the price that is abnormal for the payer and two procedure codes that are not allowed in the same claim by the payer. - View Dependent Claims (2, 3, 4, 5, 6, 7)
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8. An apparatus healthcare claim decision support, comprising:
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a processor and a memory, the processor executing a plurality of lines of instructions that cause the processor to be configured to; receive streaming transactional healthcare claim data; extract a healthcare eligibility data stream, a healthcare claim submission data stream and a healthcare claim payment data stream from the streaming transactional healthcare claim data; aggregate a message from the healthcare eligibility data stream, a message from the healthcare claim submission data stream and a message from the healthcare claim payment data stream about a particular claim being submitted to a payer; perform a sliding window analysis to the aggregated messages about the particular claim being submitted to the payer to identify healthcare claim data in the aggregated messages that is relevant to the particular claim being submitted to the payer; perform a frequent item set process on the identified healthcare claim data in the aggregated messages to determine a procedure code that does not match a service code; perform a price analysis of the identified healthcare claim data in the aggregated messages to identify a price for a service or procedure in the claim that is abnormal for the payer; perform a code co-occurrence of the identified healthcare claim data in the aggregated messages to identify two procedure codes that are not allowed in the same claim by the payer; and generate user interfaces that show, for the particular claim to the payer, one or more issues with the claim based on the procedure code that does not match the service code, the price that is abnormal for the payer and two procedure codes that are not allowed in the same claim by the payer. - View Dependent Claims (9, 10, 11, 12, 13, 14)
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Specification