Insurance information management system and method
First Claim
1. An automated system for managing insurance information and processing insurance claims, the automated system residing on a host server and comprising:
- means for capturing and maintaining disablement information including a network interface and a user interface for capturing the disablement information and a database for storing the disablement information; and
processing tools for processing the disablement information, the processing tools comprising a benefits calculation engine for determining benefits payable, the benefits calculation engine comprising a plurality of formulas, each formula corresponding to specific disablement information, wherein the benefits calculation engine calculates benefits for multiple reimbursement products available for multiple disablement scenarios.
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Accused Products
Abstract
An automated system for managing insurance information is provided. The system resides on a host server and communicates with participants and providers over a network. The system includes a database for storing information and processing tools including customer service tools, claim adjudication tools, and a benefits calculation engine. The benefits calculation engine calculates an applicable benefit based on received information. The system further comprises benefit payment processing tools for paying a benefit and expense payment processing and adjustment tools. The system also includes claim reporting tools for performing reporting functions and claim management and plan loading tools for identifying a plan and updating the benefits calculation engine.
94 Citations
36 Claims
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1. An automated system for managing insurance information and processing insurance claims, the automated system residing on a host server and comprising:
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means for capturing and maintaining disablement information including a network interface and a user interface for capturing the disablement information and a database for storing the disablement information; and
processing tools for processing the disablement information, the processing tools comprising a benefits calculation engine for determining benefits payable, the benefits calculation engine comprising a plurality of formulas, each formula corresponding to specific disablement information, wherein the benefits calculation engine calculates benefits for multiple reimbursement products available for multiple disablement scenarios. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11)
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12. An automated system for managing insurance information and processing insurance claims, the automated system residing on a host server and comprising:
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a network interface for communicating with a client over a network;
a user interface for allowing manual data entry;
a database for storing insurance data entering the system through the network interface and the user interface; and
processing tools for processing the insurance data, the processing tools comprising, customer service tools including claim display means for displaying claim data, data maintenance means, correspondence tools for generating letters, and tracking means for tracking policyholders and claimants;
claim adjudication tools including means for tracking claimant data, means for tracking plans of care, means for tracking historical data by claim, and means for tracking final adjudication data;
a benefits calculation engine for automatically calculating benefits payable;
benefit payment processing tools including means for minimizing key entry, means for automating reimbursement claims, and means for calculating interest amounts;
expense payment processing and adjustment tools including means for processing reimbursement vendor bills, means for reconciling vendor bills with services performed, means for applying payments by claim to benefit and expense accounts, means for producing expense reports, and means for allowing changes to payments;
claim reporting tools for performing financial reporting, valuation, statistical analysis, partnership reporting, and experience analysis; and
claim management and plan loading tools including means for instructing the system in order to properly operate the benefits calculation engine, the claim management and plan loading tools including means for identifying a plan, its coverages, and coverage limits. - View Dependent Claims (13, 14, 15, 16, 17, 18, 19, 20)
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21. A method for reducing the manual effort involved in insurance claims payment, benefits calculation, and vendor bill calculation, the method comprising using an automated system for performing the steps of:
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capturing disablement information for adjudication, claims management, and pricing;
performing automated benefits calculation for existing plans with a benefits calculation engine;
providing means for loading future plan calculations and eligibility;
performing statutory and internal reporting and feeds; and
downloading policyholder information to set up and administer claims. - View Dependent Claims (22, 23, 24, 25, 26, 27, 28, 29)
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30. A method for automatically processing a request for insurance benefits, the method comprising:
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receiving a benefit request;
accessing captured disablement information to determine an appropriate benefit;
searching for a formula that corresponds to the appropriate benefit, each formula including at least one calculation step selected from a total dollars step that generates an amount for indemnity benefits, a MAX step that limits an amount payable to a maximum, an EP step that requires an elimination period to be met prior to payment, and a PCT step that pays a fixed percentage of remaining funds;
modifying an existing formula to correspond to an appropriate benefit if the appropriate benefit has no corresponding formula; and
using the corresponding formula to calculate a benefit. - View Dependent Claims (31, 32, 33, 34, 35, 36)
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Specification