Payment assurance and claim pre-validation

• US 10,318,923 B1
• Filed: 08/01/2012
• Issued: 06/11/2019
• Est. Priority Date: 08/01/2012
• Status: Active Grant

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: MacLeod, David
• Primary Examiner(s): Le, Linh Giang
• Application Number:
  US13/564,047
• Time in Patent Office: 2,505 Days
• Field of Search: None
• CPC Class Codes: G06Q 10/10 Office automation; Time management

Abstract

Methods and systems for payment assurance and claim pre-validation are described. In one embodiment, a pre-visit claim for health care related services is received for payment assurance. In response to the pre-visit claim, a payer is queried for pre-visit claim detail information indicating any payment or authorization issues for services to be rendered. The pre-visit claim may be updated in certain embodiments based on the pre-visit claim detail information, and an appointment may be scheduled for services. In other aspects, a claim for health care related services is received for pre-validation. In response, a payer is queried for claim detail information indicating any payment or authorization issues for the claim. The claim may be updated in certain embodiments based on the claim detail information, and payment for services rendered may be provided by a payer in response to a submitted claim.

Claims

1. An electronic exchange system for payment assurance and claim pre-validation, comprising:

an assurance network including an assurance server,

the assurance server further including;

standard network interfaces, configured to facilitate the following communications directly between the assurance server and subscribing providers and subscribing payers to the assurance network;

receive a pre-visit claim for health care related services from at least one subscribing provider,

in response to the pre-visit claim, query at least one subscribing payer for pre-visit claim detail information,

receive the pre-visit claim detail information from the at least one subscribing payer, the pre-visit claim detail information including indicators of one or more payment or authorization issues,

receive a confirmation of an appointment for the health care related services from the at least one subscribing provider,

in advance of the appointment, communicate updates to the payment or authorization issues from one or more of the at least one subscribing payers, and

after the appointment, submit a claim for the health care related services administered during the appointment to the subscribing payer for adjudication of the claim in real time; and

one or more translators for transforming data syntax and protocol and non-standard interfaces, configured to facilitate the following communications indirectly between the assurance server and at least one subscribing provider and at least one non-subscribing payer to the system;

receive a pre-visit claim for health care related services from a subscribing provider in a standard assurance network data format and translate by a translator the pre-visit claim into a non-standard assurance network data format,

in response to the pre-visit claim, query at least one non-subscribing payer with the non-standard assurance network data format pre-visit claim message for pre-visit claim detail information,

receive a pre-visit claim detail information from the at least one non-subscribing payer in the non-standard assurance network data format at the translator and translate the pre-visit claim information into the standard assurance network data format for the subscribing provider, the pre-visit claim detail information including indicators of payment or authorization issues,

receive a confirmation message of an appointment for the health care related services from the subscribing provider in the standard assurance network data format and translate by the translator the confirmation message into a non-standard assurance network data format for the at least one non-subscribing payer,

in advance of the appointment, communicate updates to the payment or authorization issues from the at least one non-subscribing payer to the subscribing provider, wherein the translator translates the at least one non-subscribing payers updates message from the non-standard assurance network data format to the standard assurance network data format for the subscribing provider, and

after the appointment, receive a claim for the health care related services administered during the appointment and synthetically adjudicate the claim by the assurance network based on non-real time eligibility and adjudication data provided to the assurance network by the non-subscribing payer.

2. The system of claim 1, wherein the assurance server is further configured to

query the non-subscribing payer for authorization of each line item of services rendered during the appointment, wherein a query to a non-subscribing payer is presented in the non-standard assurance network data format via the translator,

in response to the query of each line item, receive pre-validation claim detail information from the non-subscribing payer, wherein the pre-validation claim detail information from the non-subscribing payer is presented to the subscribing provider in the standard assurance network data format via the translator,

receive revisions to the claim based on the pre-validation claim detail information from the subscribing provider at the translator and translate revised claim to the non-standard assurance network data format, and

synthetically adjudicate the claim by the assurance network based on non-real time eligibility and adjudication data provided to the assurance network by the non-subscribing payer.

3. The system of claim 2, wherein the pre-validation claim detail information includes an indicator of any line item errors or authorization issues associated with the submission of the claim.

4. The system of claim 2, wherein the assurance server is further configured to

receive at a database thereof the non-real time eligibility and adjudication data, from the non-subscribing payer, including a preliminary schedule of services including services to be rendered, service codes for the services, and non-subscribing payer covered costs for the services, based on terms of a health care related insurance agreement, the service codes for the services and non-subscribing payer covered costs for the services serving as a basis for a mock claim.

5. The system of claim 2, wherein the assurance server is further configured to

receive, from the non-subscribing payer, clinical information regarding a patient associated with the pre-visit claim for health related services, the clinical information including medical conditions of the patient, a care history of the patient, and health care related programs available to the patient.

6. The system according to claim 4, wherein the non-subscribing payer provides the non-real time eligibility and adjudication data on a daily basis.

7. The system according to claim 2, wherein the assurance server is configured to derive additional non-subscriber eligibility data from previous claim submissions and to apply this additional non-subscriber eligibility data during synthetic adjudication.