Correcting and monitoring status of health care claims

• US 20040133452A1
• Filed: 10/17/2003
• Published: 07/08/2004
• Est. Priority Date: 10/17/2002
• Status: Active Grant

• Current Assignee: Waystar Technologies Incorporated
• Original Assignee: Navicure (Waystar, Inc.)
• Inventors: Craig, Thomas, Edwards, Shawn Kevin, Bradley, Kenneth Paul, Denny, James McCahill Jr.
• Granted Patent: US 7,739,132 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

The system is an advanced, web-enabled, clearinghouse that facilitates efficient and effective claim routing, monitoring and report retrieval. A claim status summary is displayed that links directly to a rejected claim listing, wherein each rejected claim listed is a link to associated detailed claim information. The detailed claim information display has fields to edit the associated detailed claim information. During the editing process, a rules verification is performed against the edited claim information to ensure the edit comply with the known rules for the associated payer. Upon successfully completing the rules verification, the edited claim is submitted to a payer.

Claims

1. A computer implemented method for processing claims, comprising the steps of:

receiving practice identifying information;

in response to receiving the practice identifying information, displaying a claim status summary that links directly to a rejected claim listing;

in response to an activation of a rejected claim listing link, displaying the rejected claim listing wherein each rejected claim listed is a link to associated detailed claim information;

in response to an activation of a listed rejection claim link, displaying the associated detailed claim information wherein a detailed claim information display has fields to edit the associated detailed claim information;

in response to receipt of edited claim information, perform a rules verification against the edited claim information; and

upon successfully completing the rules verification, submitting an edited claim to a payer.

2. The method of claim 1 further comprising the steps of:

associating an easy to understand description with a rejection code; and

displaying the easy to understand description in conjunction with the detailed claim information.

3. The method of claim 1 further comprising the steps of:

profiling a payer response to determine a corresponding pattern; and

generating an alert when the payer response has not been received within limits determined by the corresponding pattern.

4. The method of claim 1, further comprising the steps of:

receiving claim rejection data;

analyzing the claim rejection data to determine if a rejection code is in a claim management database;

categorizing a new rejection code that is not in the claim management database into a general rejection category;

determine the general rejection category for a rejected claim; and

displaying the general rejection category.

5. The method of claim 4, wherein the step of determining the general rejection category includes selecting from a group consisting of eligibility errors, duplicate claim errors, provider enrollment errors, coding errors, patient demographic errors, and payer information errors.

6. The method of claim 4, further comprising the step of:

adding a new rule verification in response to receipt of the new rejection code.

7. The method of claim 4, comprising the steps of:

receiving new claim information;

storing the new claim information;

maintaining a claim history wherein any information associated with the new claim is edited, the edit information is stored and retrievable; and

in response to a request, displaying all associated edits.

8. The method of claim 7, comprising the steps of:

performing a rules verification against the new claim information; and

providing a rejected claim report.

9. A computer implemented method for processing claim, comprising the steps of:

receiving claim rejection data over a global computer network;

analyzing the claim rejection data to determine if a rejection code is in a claim management database;

categorizing a new rejection code that is not in the claim management database into a general rejection category;

determine the general rejection category for a rejected claim; and

displaying a claim rejection summary that includes the general rejection category.

10. The method of claim 9 further comprising the steps of:

associating an easy to understand description with the new rejection code; and

displaying the easy to understand description.

11. The method of claim 9 further comprising the steps of:

profiling a payer response to determine a corresponding pattern; and

generating an alert when the payer response has not been received within limits determined by the corresponding pattern.

12. The method of claim 9, wherein the step of determining the general rejection category includes selecting from a group consisting of eligibility errors, duplicate claim errors, provider enrollment errors, coding errors, patient demographic errors, and payer information errors.

13. The method of claim 9, further comprising the step of:

adding a new rule verification in response to receipt of the new rejection code.

14. The method of claim 9, comprising the steps of:

receiving new claim information;

storing the new claim information;

maintaining a claim history wherein any information associated with the new claim is edited, the edit information is stored and retrievable; and

in response to a request, displaying all associated edits.

15. The method of claim 14, comprising the steps of:

performing a rules verification against the new claim information; and

providing a rejected claim report.

16. A computer implemented method for processing claim, comprising the steps of:

receiving new claim information;

storing the new claim information;

performing a rules verification against the new claim information;

providing a rejected claim report;

receiving claim edit information associated with the new claim;

maintaining a claim history wherein any time information associated with the new claim is edited, the edit information is stored and retrievable; and

in response to a request, displaying a claim history report that provides the claim history that shows all associated edits.

17. The method of claim 16 further comprising the steps of:

submitting the new claim to a payment processing system;

receiving claim rejection data that include a rejection code from the payment processing system;

associating an easy to understand description with the rejection code; and

displaying the easy to understand description.

18. The method of claim 16 further comprising the steps of:

profiling a payer response to determine a corresponding pattern; and

generating an alert when the payer response has not been received within limits determined by the corresponding pattern.

19. The method of claim 17, further comprising the steps of:

analyzing the claim rejection data to determine if the rejection code is in a claim management database;

categorizing a new rejection code that is not in the claim management database into a general rejection category;

determine the general rejection category for a rejected claim; and

displaying the general rejection category.

20. The method of claim 19, wherein the step of determining the general rejection category includes selecting from a group consisting of eligibility errors, duplicate claim errors, provider enrollment errors, coding errors, patient demographic errors, and payer information errors.

21. The method of claim 19, further comprising the step of:

adding a new rule verification in response to receipt of the new rejection code.