Systems and methods for verifying and editing electronically transmitted claim content

• US 20040078247A1
• Filed: 05/16/2003
• Published: 04/22/2004
• Est. Priority Date: 05/16/2002
• Status: Active Grant

• Current Assignee: NDCHealth Corp. (McKesson Corp.)
• Original Assignee: NDCHealth Corp. (McKesson Corp.)
• Inventors: Pinsonneault, Roger G., Rowe, James Couser III
• Granted Patent: US 8,190,453 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/4016 involving fraud or risk level assessment in transaction processing
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

Systems and methods verify the content of an electronically transmitted claim, such as a healthcare claim by intercepting the claim, reviewing the claim'"'"'s contents, and comparing the claim to pre-established claim criteria established by a payer or both a healthcare service provider and payer. If the claim contains the appropriate content the claim is forwarded to its intended recipient, typically a payer such as an insurance company or government healthcare payer; otherwise the claim may be returned to the sender, e.g., a pharmacy, with an indication that it does not contain the correct content. Additionally, the claim may be edited by the system and forwarded in correct form to its intended recipient.

Claims

1. A method for verifying the content of an electronically transmitted claim, thereby reducing the likelihood that said claim need be transmitted multiple times, comprising:

intercepting a claim generated by a provider, wherein said claim comprises a plurality of claim contents and wherein said claim is directed to a recipient;

reviewing said plurality of claim contents;

comparing said plurality of claim contents to pre-established claim criteria established by said recipient; and

where said plurality of claim contents meet said pre-established claim criteria, forwarding the claim to said recipient identified by at least of said plurality of claim contents.

2. The method of claim 1, further comprising returning the claim to the provider with an indication that said claim does not contain the correct claim contents when at least one of said plurality of claim contents fails to meet said pre-established criteria.

3. The method of claim 1, further comprising forwarding a pre-defined message to the provider when at least one of said plurality of claim contents fails to meet said pre-established criteria.

4. The method of claim 1, further comprising editing at least one of said plurality of claim contents when said plurality of claim contents fail to meet said pre-established claim criteria.

5. The method of claim 4, wherein editing at least one of said plurality of claim contents comprises editing at least one of said plurality of claim contents when said pre-established claim criteria instruct said edit.

6. The method of claim 4, further comprising forwarding the edited claim to said recipient identified by at least of said plurality of claim contents.

7. The method of claim 4, wherein editing comprises editing at least one of said plurality of claim contents to create an edited claim meeting said pre-established claim criteria.

8. The method of claim 4, further comprising storing said at least one of said plurality of claim contents prior to said editing.

9. The method of claim 8, further comprising storing said at least one of said edited claim contents after said editing.

10. A system for verifying the content of an electronically transmitted claim, comprising:

a provider device, wherein said provider device is operable to generate a claim comprising a plurality of claim contents and directed to a recipient in said system; and

a host server, in electrical communication with the provider device, wherein said host server is operable to intercept said claim and forward said claim to a payer editing module, where said payer editing module is operable to compare said plurality of claim contents to claim criteria provided to said host server by said recipient, and

wherein said payer editing module is operable to forward said claim to said recipient when said plurality of claim contents meet said claim criteria.

11. The system of claim 10, wherein said host server comprises said payer editing module.

12. The system of claim 10, further comprising at least one database, wherein said at least one database stores said claim criteria provided by said recipient.

13. The system of claim 10, wherein said provider device is operable to generate a pharmaceutical claim.

14. The system of claim 10, wherein said payer editing module is operable to transmit a reject message to said recipient when said plurality of claim contents fail to meet said claim criteria.

15. The system of claim 10, wherein said payer editing module is operable to edit said claim such that said edited claim meets said claim criteria.

16. The system of claim 10, wherein said payer editing module is operable to edit said claim based on said claim criteria, such that said edited claim meets said claim criteria.

17. The system of claim 10, wherein said claim criteria instruct said payer editing module to edit said claim such that said edited claim meets said claim criteria.

18. The system of claim 10, wherein said recipient is in electrical communication with said host server via the Internet.