Automated claim repricing system
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Accused Products
Abstract
The present claim repricing system generally includes a processor and a program and data memory coupled to the processor. The memory stores the requisite database tables, as well as program instructions for repricing several different types of claims, including physician, inpatient, and outpatient claims. The claim repricing system includes instructions for determining availability of insurance plan coverage to the patient based on an effective date of the employer insurance plan, as well as determining the availability of the physician or provider based on an effective provider date. The claim repricing system further handles specialty codes and exceptions. For example, the claim repricing system includes instructions for determining the presence of anesthesia specialty codes, and for determining the correct number of anesthesia units and an anesthesia repricing indicator. The anesthesia repricing indicator may be a percentage discount, for example, or a rate. Furthermore, the claim repricing system may operate in a batch processing mode to quickly, accurately, and reliable reprice large amounts of claims.
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Citations
52 Claims
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1-33. -33. (Cancelled)
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34. A claim processing system for repricing insurance claims, the system comprising:
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a processor; and
a memory coupled to said processor, said memory encoded with;
instructions for identifying at least one identifier;
instructions for determining a repricing indicator based at least in part on said one identifier;
instructions for performing a course validation to determine if said at least one identifier is present;
instructions for repricing service charges according to said repricing indicator to generate repriced service charges; and
instructions for performing a detailed validation to determine if said repriced service charges are valid. - View Dependent Claims (35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48)
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49. A claim processing system for repricing insurance claims, the system comprising:
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a processor; and
a memory coupled to said processor, said memory encoded with;
instructions for identifying at least one provider service category from a database of provider service categories;
instructions for identifying at least one per diem amount from a database of per diem amounts;
instructions for determining a repricing indicator based on an affiliation of said provider service category and per diem amount; and
instructions for repricing the service charges according to the repricing indicator to generate repriced service charges. - View Dependent Claims (50, 51, 52)
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Specification