System and method for processing and managing claim forms

• US 20040249665A1
• Filed: 06/09/2003
• Published: 12/09/2004
• Est. Priority Date: 06/09/2003
• Status: Abandoned Application

• Current Assignee: Janssen Ortho Inc (Johnson & Johnson)
• Original Assignee: Janssen Ortho Inc (Johnson & Johnson)
• Inventors: David, Lindee
• Application Number:
  US10/456,556
• Publication Number:
  US 20040249665A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

The invention provides a system and method for processing and managing medical insurance claim forms. A computer software system is provided for implementing the system and method. A user of the computer software system may use it to retrieve data about patient, physicians, and insurance providers from data bases provided by the computer software system and enter retrieved data automatically into claim forms for submission to an insurance provider. Documentation for seeking pre-approval of a treatment, making insurance claims, or appeal rejection of claims by an insurance provider may be generated using the software system. Claim processing status, whether a claim is submitted and still pending, rejected, appealed, or approved, may be tracked and managed using the computer software system. The computer software system also provides access to both legal and medical reference information to justify or support an insurance claim.

Claims

1. A system for preparing and tracking an insurance claim for an insurance provider identified from a plurality of insurance providers for a pharmaceutical product for a patient from a plurality of patients, said system comprising:

a database for storing patient information relating to said patient, claim information relating to said insurance claim, form information relating to said plurality of insurance providers, provider information relating to said plurality of insurance providers and product information relating to said pharmaceutical product;

a software system operating on a computer for entering and processing said patient information, claim information, provider information and product information, said software system adapted to receive said patient information from a user, to identify said claim information utilizing in part said patient information and to track a status of said insurance claim as it is processed by said insurance provider.

2. The system of claim 1 wherein said software system further is adapted to generate a claim package for said insurance claim, said claim package comprising a claim form related to said insurance provider populated by data in said patient information and a covering letter addressed to said insurance provider providing further information relating to said patient and said pharmaceutical product.

3. The system of claim 2 wherein said product information comprises dosage information, treatment information and clinical study information.

4. The system of claim 3 wherein said software system is further adapted to selectively include said clinical study information as said further information in said covering letter.

5. The system of claim 4 wherein said software system tracks said status of said insurance claim as being one of at least being pending, filed, and rejected.

6. The system of claim 5 wherein said software system is further adapted to selectively generate an appeal package after said status of said insurance claim is set to being rejected, said appeal package comprising an appeal covering letter providing further information from said clinical study information.

7. The system of claim 6 wherein said software system is further adapted to generate a status report comprising claim status information relating to claims prepared for said plurality of patients.

8. The system of claim 7 wherein said software system is further adapted to track a plurality of physicians of patients that file insurance claims relating to said pharmaceutical product to said plurality of insurance providers and said database contains physician information relating to said plurality of physicians.

9. The system of claim 8 wherein said software system is further adapted to generate a report based one of a condition relating to said pharmaceutical product, said patient and a physician of said plurality of physicians.

10. The system of claim 9 wherein said database stores said patient information, said claim information, said provider information, said product information and said physician information in a plurality of tables and said software system is adapted to access and process said plurality of tables using SQL constructs.

11. A method of preparing and tracking an insurance claim for an insurance provider identified from a plurality of insurance providers for a pharmaceutical product for a patient from a plurality of patients, a status of said insurance claim being stored in a database accessible by a software system operating on a computer, said software system adapted to receive data relating to said insurance claim and to generate a claim package relating to said insurance claim, said method comprising the steps of:

receiving said patient information from a user by said software system;

providing product information relating to said pharmaceutical product for inclusion in said claim package for selection by said user;

generating said claim package utilizing said received patient information and product information;

tracking a status of said insurance claim; and

updating said status upon a user being notified of approval or rejection of the insurance claim.

12. The method of claim 11, wherein

said product information comprises dosage information, treatment information and clinical study information;

and

said method further comprises providing said clinical study information into said insurance claim documentation in a form letter.

13. A method of assessing a patient, and preparing and tracking an insurance claim for an insurance provider identified from a plurality of insurance providers for a pharmaceutical product identified by said assessment for treatment of said patient from a plurality of patients, a status of said insurance claim being stored in a database accessible by a software system operating on a computer, said software system adapted to receive data relating to said insurance claim and to generate a claim package relating to said patient assessment and said insurance claim, said method comprising the steps of:

receiving patient assessment information from a user by said software system;

providing diagnosis information based on said patient assessment information;

providing treatment information based on said diagnosis; and

when said treatment information identifies a pharmaceutical product;

receiving said patient information from a user by said software system;

providing product information relating to said pharmaceutical product for inclusion in said claim package for selection by said user;

generating said claim package utilizing said received patient information and product information;

tracking a status of said insurance claim; and

updating said status upon a user being notified of approval or rejection of the insurance claim.