System and method for processing and pre-adjudicating patient benefit claims
First Claim
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1. A rules-based benefit claim pre-adjudication method for maximizing service provider/medical facility administrative and clinical efficiencies comprising the steps of:
- generating a patient benefits plan at the service provider/medical facility location;
defining the treatments and conditions of a patient claim for benefits;
analyzing the patient claim for benefits to generate a preliminary EOB and to determine medical necessity protocols as defined by patient benefit plan and PIC standards;
verifying compliance of treatments and conditions in the patient claim for benefits with applicable standards;
predetermining monetary allowance for medical services rendered based upon applicable payment schedules; and
submitting the pre-adjudicated claim to a designated payer in accordance with the patient benefit plan.
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Abstract
A system and method for a rules-based pre-adjudication of a benefits claim submission is disclosed, wherein a patient claim benefit is pre-adjudicated in accordance with proprietary and commercial rules prior to submission to a policy issuing company to assure compliance with the terms and conditions of the patient benefit plan and to minimize error and maximize benefit reimbursement. Treatment plans are generated by examining treatments and conditions codes to arrive at appropriate treatment plans that identify other applicable treatments and conditions codes.
240 Citations
18 Claims
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1. A rules-based benefit claim pre-adjudication method for maximizing service provider/medical facility administrative and clinical efficiencies comprising the steps of:
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generating a patient benefits plan at the service provider/medical facility location;
defining the treatments and conditions of a patient claim for benefits;
analyzing the patient claim for benefits to generate a preliminary EOB and to determine medical necessity protocols as defined by patient benefit plan and PIC standards;
verifying compliance of treatments and conditions in the patient claim for benefits with applicable standards;
predetermining monetary allowance for medical services rendered based upon applicable payment schedules; and
submitting the pre-adjudicated claim to a designated payer in accordance with the patient benefit plan. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15)
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16. A rules-based system for pre-adjudication of a benefits claim, said system comprising:
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a source of claim data capable of identifying patient demographics and benefits plan coverage;
means at a benefit provider site for accessing the claim data source to capture historical claim data and update patient'"'"'s current information;
at least one set of pre-adjudication rules corresponding to the type of patient benefits plan coverage; and
audit processing means for validating in accordance with said at least one set of pre-adjudication rules treatments and conditions coding and identifying applicable related treatments and conditions codes corresponding to the patient'"'"'s diagnosis and prior treatment history to generate a suggested treatment plan to the provider whereby treatments are matched with conditions and applicable excluded treatments codes are identified. - View Dependent Claims (17)
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18. A method for pre-adjudication of benefits claim submission to a payer, said method comprising the steps of:
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preparing benefits claim data including identifying a patient, an insured covering the patient, benefit policy and plan codes applicable to the patient and treatments codes corresponding to conditions performed on the patient by a provider;
analyzing the benefits claim data in accordance with at least one set of predefined rules for conformity of claim data elements to a set of pre-established criteria;
validating the treatments and conditions codes specified in the benefits claim data;
verifying that the correct coding initiatives comply with the benefits policy and plan code identified in the benefits claim data preparation step;
valuating each benefit associated with the specified treatments and conditions codes;
reviewing each identified benefit value in accordance with the Policy Issuing Company agreement terms and conditions and generating a corresponding acceptance message or correction request message;
forwarding the benefits claim to the Policy Issuing Company identified in the benefit claim data preparation step;
presenting the benefits claim to the Policy Issuing Company for generation of an EOB in response to the benefit claim complying with the claim request requirements or in response to provider instructions;
reviewing the PIC-generated EOB to capture remark codes to determine priority of action and generating corresponding trigger messages in response thereto and identifying rule deviations corresponding to benefits claim payments made and non-payment of qualifying benefits claim;
updating said at least one set of predefined rules to incorporate changes resulting from the PIC-generated EOB review step; and
generating messages reflecting priority of benefits claim coding to maximize provider reimbursement.
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Specification