System and method for managing liability insurer healthcare claims
First Claim
1. A system for managing healthcare claims, for which liability insurers are financially responsible, comprising:
- a) at least one system administrator in privity, directly or indirectly, with at least one healthcare provider member, and at least one liability insurer member;
b) at least one passive healthcare provider network including said at least one healthcare provider member having a set of network provider rules; and
, c) at least one liability insurer network including said at least one liability insurer member having a set of policy rules wherein said at least one system administrator receives claims, applies said network provider rules, transmits said claim for application of said policy rules, and pays said claim in accordance therewith.
1 Assignment
0 Petitions
Accused Products
Abstract
A system and method for managing liability insurer'"'"'s healthcare claims, allows liability insurers, such as property and casualty insurers, who have no direct policy relationship with patients for whom they become financially responsible, to take advantage of healthcare provider “rate regulations,” and “healthcare management,” including incentives, heretofore only available to healthcare insurers from healthcare providers within an “active network.” A system administrator manages clamant healthcare claims from member passive network healthcare providers for member liability insurers that become financially responsible for these claims as a result of the actions or inactions of their liability policyholders. The liability insurer members within the insurer network are in contractual relationship with the system administrator who is in contractual relationship with member healthcare providers of the passive healthcare provider network such that when a provider of healthcare product or service submits a claim, for which a system liability insurer member is financially responsible, the system administrator validates the claim as falling in the system; applies the provider network rules; and applies provider coverage rules to determine the level of coverage by the member liability insurer for the claim. Based on this determination, that portion of the claim covered by the member liability policy the Claimant is paid by the system administrator. In another aspect, an Allocation Fund is provided to pay claims where more than one system liability insurer may be liable for the claim.
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Citations
50 Claims
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1. A system for managing healthcare claims, for which liability insurers are financially responsible, comprising:
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a) at least one system administrator in privity, directly or indirectly, with at least one healthcare provider member, and at least one liability insurer member;
b) at least one passive healthcare provider network including said at least one healthcare provider member having a set of network provider rules; and
,c) at least one liability insurer network including said at least one liability insurer member having a set of policy rules wherein said at least one system administrator receives claims, applies said network provider rules, transmits said claim for application of said policy rules, and pays said claim in accordance therewith. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16)
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17. A method for managing claims relating to healthcare provided by a member healthcare provider, for which a liability insurer, within a liability insurer network, is financially responsible, comprising the steps of:
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a) receiving a claim for healthcare;
b) applying the network rules associated with a passive healthcare provider network in which said healthcare provider is a member, to the claim;
c) applying the policy rules associated with the member liability insurer network to the claim;
d) processing the appropriate payment of the claim. - View Dependent Claims (18, 19, 20, 21, 22)
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23. A method for facilitating compliance with policy rules governing coverage by a liability insurer for healthcare provided to a Claimant by a member healthcare provider comprising the steps of:
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b) receiving a liability generated claim for healthcare;
c) applying provider network rules to said claim;
d) determining the level of liability coverage for the claim; and
e) processing payment or authorization to provide healthcare for said claim based thereon. - View Dependent Claims (24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36)
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37. A system for facilitating compliance with policy rules governing coverage by a liability insurer for healthcare provided to a Claimant by a member healthcare provider, wherein the healthcare is administered under provider network rules in a passive healthcare provider network comprising:
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a) means for receiving a liability claim for said healthcare;
b) means for applying said provider network rules associated with said passive healthcare provider network;
c) means for applying said policy rules governing coverage by a liability insurer of said claim;
d) means for approving the level of coverage by the liability insurer for said claim; and
,e) means for processing payment for said claim. - View Dependent Claims (38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50)
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Specification